1740309418 NPI number — PRZEMYSLAW MATEUSZ KAMIEN M.D.

Table of content: PRZEMYSLAW MATEUSZ KAMIEN M.D. (NPI 1740309418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740309418 NPI number — PRZEMYSLAW MATEUSZ KAMIEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAMIEN
Provider First Name:
PRZEMYSLAW
Provider Middle Name:
MATEUSZ
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1740309418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9650 GROSS POINT RD STE 2900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-1214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-866-7846
Provider Business Mailing Address Fax Number:
866-854-5815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9650 GROSS POINT RD STE 2900
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60076-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-866-7846
Provider Business Practice Location Address Fax Number:
866-854-5815
Provider Enumeration Date:
03/27/2007

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: 207X00000X , with the licence number:  49765 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 036130340 , 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: 036.120340 . This is a "STATE OF ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATIONS." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 201114620 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 542125000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000791353 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35273100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: ENROLLED , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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