Healthcare Provider Details

I. General information

NPI: 1154368025
Provider Name (Legal Business Name): HENRY M BARANIEWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/28/2013
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

1740 W TAYLOR ST 2200 UICH, MC 957
CHICAGO IL
60612-7232
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7699
  • Fax:
Mailing address:
  • Phone: 312-996-7595
  • Fax: 312-996-2704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036-079128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: