Provider Demographics
NPI:1457377723
Name:KRICHAVSKY, MARC Z (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:Z
Last Name:KRICHAVSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 GERMANTOWN RD
Mailing Address - Street 2:GALTER 19-100
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5036
Mailing Address - Country:US
Mailing Address - Phone:203-794-0090
Mailing Address - Fax:203-830-4614
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:GALTER 19-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-4965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036123774207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA38812Medicare UPIN