Healthcare Provider Details

I. General information

NPI: 1518072024
Provider Name (Legal Business Name): JAROSLAUS T IWANETZ MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E 142ND ST
DOLTON IL
60419-1062
US

IV. Provider business mailing address

713 E 142ND ST
DOLTON IL
60419-1062
US

V. Phone/Fax

Practice location:
  • Phone: 708-841-1121
  • Fax: 708-841-6976
Mailing address:
  • Phone: 708-841-1121
  • Fax: 708-841-6976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042003889
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number042003889
License Number StateIL

VIII. Authorized Official

Name: BOHDAN A IWANETZ
Title or Position: PHYSICIAN SECRETARY OF CORP
Credential: MD
Phone: 708-841-1121