Healthcare Provider Details

I. General information

NPI: 1538366158
Provider Name (Legal Business Name): BRIAN EDMUND WALCZAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 OGDEN AVE
AURORA IL
60504-7597
US

IV. Provider business mailing address

2111 OGDEN AVE
AURORA IL
60504-7597
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101017411
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number106196
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036163012
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number518269
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036163012
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: