1659860872 NPI number — JOANNA WIECKOWSKA DO

Table of content: JOANNA WIECKOWSKA DO (NPI 1659860872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659860872 NPI number — JOANNA WIECKOWSKA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIECKOWSKA
Provider First Name:
JOANNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1659860872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776982
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:
60677-6982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-494-5797
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1560 E SHERMAN BLVD
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49444-1854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-672-6186
Provider Business Practice Location Address Fax Number:
231-672-6181
Provider Enumeration Date:
05/02/2018

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: 207R00000X , with the licence number:  5101023799 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 5101028236 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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