Provider Demographics
NPI:1295742856
Name:LYUGEN ADULT CLINIC P.C.
Entity type:Organization
Organization Name:LYUGEN ADULT CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIROSHNICHECNKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-404-0160
Mailing Address - Street 1:7013 LOREL AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3489
Mailing Address - Country:US
Mailing Address - Phone:773-465-6533
Mailing Address - Fax:
Practice Address - Street 1:7013 LOREL AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3489
Practice Address - Country:US
Practice Address - Phone:773-465-6533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209449Medicare ID - Type Unspecified
ILH66323Medicare UPIN