Provider Demographics
NPI:1013993914
Name:DOREVITCH, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DOREVITCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5336 N LAKEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2209
Mailing Address - Country:US
Mailing Address - Phone:773-334-9029
Mailing Address - Fax:312-996-0064
Practice Address - Street 1:75 REMITTANCE DR
Practice Address - Street 2:SUITE 1951
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60675-1001
Practice Address - Country:US
Practice Address - Phone:847-535-5917
Practice Address - Fax:847-535-5801
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36083148207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36083148Medicaid
ILL36454Medicare ID - Type Unspecified
ILF28511Medicare UPIN