Provider Demographics
NPI:1871870683
Name:CHICAGO ANTI-AGING AND VEIN SPECIALISTS LLC
Entity type:Organization
Organization Name:CHICAGO ANTI-AGING AND VEIN SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMM, CPC, CEMC
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-904-7500
Mailing Address - Street 1:2921 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1507
Mailing Address - Country:US
Mailing Address - Phone:312-729-5522
Mailing Address - Fax:
Practice Address - Street 1:905 TAMER LN
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3768
Practice Address - Country:US
Practice Address - Phone:847-904-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.124097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty