Provider Demographics
NPI:1881828861
Name:TATJANA K PAVLOVIC, MD SC
Entity Type:Organization
Organization Name:TATJANA K PAVLOVIC, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TATJANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PAVLOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-271-2719
Mailing Address - Street 1:2719 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3919
Mailing Address - Country:US
Mailing Address - Phone:773-271-2719
Mailing Address - Fax:
Practice Address - Street 1:2719 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3919
Practice Address - Country:US
Practice Address - Phone:773-271-2719
Practice Address - Fax:773-271-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062416207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1881828861Medicare NSC
IL0444260001Medicare NSC