Provider Demographics
NPI:1043482250
Name:HOSEP H DEYRMENJIAN, MD, PC
Entity type:Organization
Organization Name:HOSEP H DEYRMENJIAN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSEP
Authorized Official - Middle Name:H
Authorized Official - Last Name:DEYRMENJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-855-3150
Mailing Address - Street 1:6440 GRAND AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5257
Mailing Address - Country:US
Mailing Address - Phone:847-855-3150
Mailing Address - Fax:847-855-3143
Practice Address - Street 1:6440 GRAND AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5257
Practice Address - Country:US
Practice Address - Phone:847-855-3150
Practice Address - Fax:847-855-3143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36079535207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36079535Medicaid
IL4920692OtherBLUE CROSS BLUE SHIELD
IL36079535Medicaid