Basic Information
| Provider Information | |||||||||
| NPI: | 1780620864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYNNYCHENKO | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 W IL ROUTE 22 DEPT OF | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600101919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473810123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | DEPARTMENT OF ANESTHESIA | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702760 | ||||||||
| FaxNumber: | 8475702921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 036100119 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP3000X | 036100119 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 036100119 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.