1336152891 NPI number — P JOHN KONICKI DO

Table of content: P JOHN KONICKI DO (NPI 1336152891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336152891 NPI number — P JOHN KONICKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONICKI
Provider First Name:
P
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1336152891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4440 W 95TH ST
Provider Second Line Business Mailing Address:
DEPARTMENT OF EMERGENCY MEDICINE
Provider Business Mailing Address City Name:
OAK LAWN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60453-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-684-5354
Provider Business Mailing Address Fax Number:
708-684-1028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 W 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-353-5252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2006

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: 207PE0004X , with the licence number:  036091309 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 02005798A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36091309 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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