Healthcare Provider Details

I. General information

NPI: 1740201664
Provider Name (Legal Business Name): MARIAN KOWALCZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 N HARLEM AVE STE 202
CHICAGO IL
60634-4683
US

IV. Provider business mailing address

3020 EDGEMONT LN
PARK RIDGE IL
60068-2155
US

V. Phone/Fax

Practice location:
  • Phone: 773-282-4793
  • Fax: 773-282-4844
Mailing address:
  • Phone: 773-282-4793
  • Fax: 773-282-4844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-101289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: