Provider Demographics
NPI:1407842958
Name:POTERMIN, ALEXANDER V (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:V
Last Name:POTERMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1120 THOMPSON BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1021
Mailing Address - Country:US
Mailing Address - Phone:847-354-8086
Mailing Address - Fax:800-619-0893
Practice Address - Street 1:1120 THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1021
Practice Address - Country:US
Practice Address - Phone:847-354-8086
Practice Address - Fax:800-619-0893
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36104917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L88883Medicare ID - Type Unspecified
H50777Medicare UPIN