Healthcare Provider Details

I. General information

NPI: 1255508222
Provider Name (Legal Business Name): AGATA JURKIEWICZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 N WILTON AVE 2ND FLOOR
CHICAGO IL
60657-6710
US

IV. Provider business mailing address

836 W WELLINGTON AVE ROOM 7403
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5424
  • Fax: 773-296-5280
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125051934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: