MEDICARE: DR. ELIZABETH MARIE WOLLENSAK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	036.137629	IL

General Provider Information

NPI Number	:	1508132507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH MARIE WOLLENSAK D.O.

Provider Business Mailing Address
First Line	:	6853 NORTH AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1023
Country	:	US
Telephone Number	:	708-383-3010
Fax Number	:	708-383-6475

Provider Business Practice Location Address
First Line	:	6853 NORTH AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1023
Country	:	US
Telephone Number	:	708-383-3010
Fax Number	:	708-383-6475

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2012
Last Update Date	:	04/15/2023

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