Basic Information
Provider Information | |||||||||
NPI: | 1720054950 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ASSIMACOPOULOS | ||||||||
FirstName: | ARISTIDES | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 901 MCCLINTOCK DR STE 201 | ||||||||
Address2: |   | ||||||||
City: | BURR RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 605270872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6304699200 | ||||||||
FaxNumber: | 6306541865 | ||||||||
Practice Location | |||||||||
Address1: | 890 GARFIELD AVE STE 210 | ||||||||
Address2: |   | ||||||||
City: | LIBERTYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 600483100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478166538 | ||||||||
FaxNumber: | 8478167217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2006 | ||||||||
LastUpdateDate: | 07/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036133426 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RI0200X | 45650 | AZ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 036-133426 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 09739 | 01 | IA | BCBS | OTHER | 55G66AS | 01 | MN | BCBS | OTHER | 150576001 | 05 | AR |   | MEDICAID | 667295 | 05 | AZ |   | MEDICAID | 8005636 | 05 | CA |   | MEDICAID | P01180015 | 01 | AZ | RAILROAD MEDICARE | OTHER | 406083100 | 05 | MN |   | MEDICAID |