1316203896 NPI number — JEFF D. KAZMIERCZAK, PSY.D., P.C.

Table of content: ROBERT VINCENT BARTHEL M.D. (NPI 1386605087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316203896 NPI number — JEFF D. KAZMIERCZAK, PSY.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFF D. KAZMIERCZAK, PSY.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1316203896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2626 FLOSSMOOR RD
Provider Second Line Business Mailing Address:
2E
Provider Business Mailing Address City Name:
FLOSSMOOR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60422-1555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-412-2778
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 HERITAGE DR
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
BOURBONNAIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60914-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-933-8760
Provider Business Practice Location Address Fax Number:
815-933-9061
Provider Enumeration Date:
04/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KAZMIERCZAK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
773-412-2778

Provider Taxonomy Codes

  • Taxonomy code: 103TA0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TR0400X , with the licence number: 071008293 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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