Healthcare Provider Details

I. General information

NPI: 1003968157
Provider Name (Legal Business Name): TRAUMA AND SURGICAL SPECIALISTS OF DUPAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 10/14/2011
Certification Date:
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL J. IWANICKI
Title or Position: OWNER
Credential: D.O.
Phone: 603-275-3892