Provider Demographics
NPI:1104056449
Name:KISHKURNO, SERGUEI V (MD)
Entity type:Individual
Prefix:
First Name:SERGUEI
Middle Name:V
Last Name:KISHKURNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 W 95TH ST # 250N
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2600
Mailing Address - Country:US
Mailing Address - Phone:708-684-5722
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST # 250N
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067835A208000000X, 2080N0001X
NY2449752080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics