Provider Demographics
NPI:1043326317
Name:MACKAVICH, DERRICK ANTHONY (DO)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:ANTHONY
Last Name:MACKAVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 W HENDERSON ST # 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2103
Mailing Address - Country:US
Mailing Address - Phone:773-327-5058
Mailing Address - Fax:773-327-5058
Practice Address - Street 1:2320 E 93RD ST
Practice Address - Street 2:ADVOCATE TRINITY HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3983
Practice Address - Country:US
Practice Address - Phone:773-967-2000
Practice Address - Fax:773-967-2000
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110111 1Medicaid
IL0001620300OtherBLUECROSS BLUESHILD OF IL
ILK04208Medicare PIN
IL036110111 1Medicaid