1013124403 NPI number — WIESLAW ROBERT DYBOWSKI

Table of content: WIESLAW ROBERT DYBOWSKI (NPI 1013124403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013124403 NPI number — WIESLAW ROBERT DYBOWSKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYBOWSKI
Provider First Name:
WIESLAW
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013124403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 56341
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60656-0341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-867-4949
Provider Business Mailing Address Fax Number:
708-867-4981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3249 OAK PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-3429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-502-4221
Provider Business Practice Location Address Fax Number:
773-404-2086
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  238000076 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01637103 . This is a "BLUE CROSS BLUE SHIELD OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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