Provider Demographics
NPI:1831100361
Name:TRAKHTMAN, STEVEN VSEVOLOD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:VSEVOLOD
Last Name:TRAKHTMAN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8936 NILES CENTER RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1847
Mailing Address - Country:US
Mailing Address - Phone:847-606-7988
Mailing Address - Fax:800-801-6284
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 606
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-681-7877
Practice Address - Fax:800-801-6284
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP74753Medicare UPIN