Healthcare Provider Details

I. General information

NPI: 1437187366
Provider Name (Legal Business Name): ANDREW J JOHANEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

246 N WARWICK AVE
WESTMONT IL
60559-1718
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-3521
  • Fax:
Mailing address:
  • Phone: 630-541-8956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: