1619439809 NPI number — MR. PHILIP SEBASTIAN MACIUKIEWICZ M.D.

Table of content: MR. PHILIP SEBASTIAN MACIUKIEWICZ M.D. (NPI 1619439809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619439809 NPI number — MR. PHILIP SEBASTIAN MACIUKIEWICZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACIUKIEWICZ
Provider First Name:
PHILIP
Provider Middle Name:
SEBASTIAN
Provider Name Prefix Text:
MR.
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:
1619439809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/07/2019
NPI Reactivation Date:
11/27/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 S FIRST AVENUE
Provider Second Line Business Mailing Address:
BUILDING 103 ROOM 3107
Provider Business Mailing Address City Name:
MAYWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-216-9169
Provider Business Mailing Address Fax Number:
708-216-1249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2160 S FIRST AVENUE
Provider Second Line Business Practice Location Address:
BUILDING 103 ROOM 3107
Provider Business Practice Location Address City Name:
MAYWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-216-9169
Provider Business Practice Location Address Fax Number:
708-216-1249
Provider Enumeration Date:
04/05/2019

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: 207L00000X , with the licence number:  125.074702 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 036.158461 , 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)





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