1396007456 NPI number — EUGENIA GROCHOWSKA MD

Table of content: (NPI 1396007456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396007456 NPI number — EUGENIA GROCHOWSKA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EUGENIA GROCHOWSKA MD
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:
EUGENIA GROCHOWSKA MD
Provider Other Organization Name Type Code:
3
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:
1396007456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5647 W LAWRENCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60630-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-545-5252
Provider Business Mailing Address Fax Number:
773-545-5671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5647 W LAWRENCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60630-3219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-545-5252
Provider Business Practice Location Address Fax Number:
773-545-5671
Provider Enumeration Date:
06/13/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GROCHOWSKA
Authorized Official First Name:
EUGENIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-545-5252

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036062717 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21609795 . This is a "BLUE CROSS BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".