Individual
LARISSA BERESTENKO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2760 WILSHIRE LN, NORTHBROOK, IL 60062-2631
(847) 809-2740
(847) 715-4894
Mailing address
2760 WILSHIRE LN, NORTHBROOK, IL 60062-2631
(847) 809-2740
(847) 715-4894
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036101565
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001627244
BLUE CROSS BLUE SHIELD
IL
05
—
036101565
—
IL
01
—
14D0981233
CLIA
IL
Enumeration date
10/23/2006
Last updated
07/08/2007
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