Basic Information
| Provider Information | |||||||||
| NPI: | 1700822376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARKEWYCZ | ||||||||
| FirstName: | BOHDAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 WEST LAKE STREET | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086813000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 207L00000X | 036083122 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036083122 | 05 | IL | MEDICAID |