Provider Demographics
NPI:1841614666
Name:CHIZHIK, MASHA
Entity type:Individual
Prefix:
First Name:MASHA
Middle Name:
Last Name:CHIZHIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1541 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1313
Practice Address - Country:US
Practice Address - Phone:773-250-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004920363AM0700X
IL085.004920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
F400222230OtherMEDICARE PTAN