Healthcare Provider Details

I. General information

NPI: 1891131926
Provider Name (Legal Business Name): DAVID MIKOLAJCZYK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY RUSH UNIVERSITY MEDICAL CENTER
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY RUSH UNIVERSITY MEDICAL CENTER
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125062701
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: