Individual
DERRICK ANTHONY MACKAVICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
2320 E 93RD ST, ADVOCATE TRINITY HOSPITAL, CHICAGO, IL 60617-3983
(773) 967-2000
(773) 967-2000
Mailing address
1435 W HENDERSON ST # 3, CHICAGO, IL 60657-2103
(773) 327-5058
(773) 327-5058
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001620300
BLUECROSS BLUESHILD OF IL
IL
05
—
036110111 1
—
IL
Enumeration date
08/21/2006
Last updated
07/09/2007
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