MEDICARE: JAROSLAUS T IWANETZ MD SC

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	207Q00000X	Family Medicine Physician	042003889	IL
2	208600000X	Surgery Physician	042003889	IL

General Provider Information

NPI Number	:	1518072024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAROSLAUS T IWANETZ MD SC

Provider Business Mailing Address
First Line	:	713 E 142ND ST
Second Line	:
City	:	DOLTON
State	:	IL
Zip	:	60419-1062
Country	:	US
Telephone Number	:	708-841-1121
Fax Number	:	708-841-6976

Provider Business Practice Location Address
First Line	:	713 E 142ND ST
Second Line	:
City	:	DOLTON
State	:	IL
Zip	:	60419-1062
Country	:	US
Telephone Number	:	708-841-1121
Fax Number	:	708-841-6976

Authorized Official
Title or Position	:	PHYSICIAN SECRETARY OF CORP
Name	:	BOHDAN A IWANETZ
Credential	:	MD
Telephone Number	:	708-841-1121

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	06/23/2008

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