Basic Information
Provider Information
NPI: 1003143801
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FEOKTISTOV
FirstName: ALEXANDER
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1460 N HALSTED ST STE 501
Address2:  
City: CHICAGO
State: IL
PostalCode: 606422615
CountryCode: US
TelephoneNumber: 7733886390
FaxNumber: 3128677101
Practice Location
Address1: 1460 N HALSTED ST STE 501
Address2:  
City: CHICAGO
State: IL
PostalCode: 606422615
CountryCode: US
TelephoneNumber: 7733886390
FaxNumber: 3128677101
Other Information
ProviderEnumerationDate: 11/16/2009
LastUpdateDate: 12/26/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X036124141ILY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


Home