1174582191 NPI number — KRISTY MARCZEWSKI FRANK OD

Table of content: KRISTY MARCZEWSKI FRANK OD (NPI 1174582191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174582191 NPI number — KRISTY MARCZEWSKI FRANK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRANK
Provider First Name:
KRISTY
Provider Middle Name:
MARCZEWSKI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARCZEWSKI
Provider Other First Name:
KRISTY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174582191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2570 DEKALB AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYCAMORE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60178-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-758-1039
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2570 DEKALB AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYCAMORE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60178-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-758-1039
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2006

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: 152W00000X , with the licence number:  046009660 , 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: 046009660 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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