Healthcare Provider Details

I. General information

NPI: 1003845561
Provider Name (Legal Business Name): MICHAEL J IWANICKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 HIGHLAND AVE TOWER 2, SUITE 107
DOWNERS GROVE IL
60515-1500
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 630-275-7800
  • Fax: 630-810-9240
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-105399
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036-105399
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: