Basic Information
| Provider Information | |||||||||
| NPI: | 1629067038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SRECKOVIC | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | ILIJA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10400 SOUTHWEST HWY | ||||||||
| Address2: | LL | ||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604151367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085817308 | ||||||||
| FaxNumber: | 7082744027 | ||||||||
| Practice Location | |||||||||
| Address1: | 15300 WEST AVE | ||||||||
| Address2: | SUITE 314 WEST | ||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083647882 | ||||||||
| FaxNumber: | 7083647886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 02/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036095069 | IL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02232706 | 01 | IL | BC BS | OTHER | K16749 | 01 | IL | MEDICARE PIN NUMBER | OTHER | 036095069 | 05 | IL | MEDICAID | 5997533 | 01 | IL | AETNA | OTHER | P00211777 | 01 | IL | RR MEDICARE | OTHER |