Healthcare Provider Details

I. General information

NPI: 1013124403
Provider Name (Legal Business Name): WIESLAW ROBERT DYBOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

PO BOX 56341
CHICAGO IL
60656-0341
US

V. Phone/Fax

Practice location:
  • Phone: 773-502-4221
  • Fax: 773-404-2086
Mailing address:
  • Phone: 708-867-4949
  • Fax: 708-867-4981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238000076
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: