Basic Information
Provider Information | |||||||||
NPI: | 1861403891 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AGOS | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | STEVE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AGOS | ||||||||
OtherFirstName: | ANDREW | ||||||||
OtherMiddleName: | STEVE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2650 RIDGE AVE STE 1223 | ||||||||
Address2: |   | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475702040 | ||||||||
FaxNumber: | 8477335315 | ||||||||
Practice Location | |||||||||
Address1: | 5140 N CALIFORNIA AVE | ||||||||
Address2: | SUITE 780 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606253645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732736810 | ||||||||
FaxNumber: | 7732735532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2006 | ||||||||
LastUpdateDate: | 02/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036093418 | IL | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0001630046 | 01 | IL | BCBS OF IL GROUP NUMBER | OTHER | 036093418 1 | 05 | IL |   | MEDICAID | 036093418 2 | 05 | IL |   | MEDICAID |