Healthcare Provider Details

I. General information

NPI: 1356575690
Provider Name (Legal Business Name): MARK CHWAJOL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MAREK CHWAJOL M.D.

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1350 N WELLS ST APT. F 203
CHICAGO IL
60610-1936
US

V. Phone/Fax

Practice location:
  • Phone: 886-600-2273
  • Fax:
Mailing address:
  • Phone: 646-675-2670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036.123878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: