Healthcare Provider Details

I. General information

NPI: 1740574748
Provider Name (Legal Business Name): JOHN ANTHONY CIESLAK III M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 04/13/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPT. OF RADIOLOGY
EVANSTON IL
60201-1057
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPT. OF RADIOLOGY
EVANSTON IL
60201-1057
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2942
  • Fax:
Mailing address:
  • Phone: 847-570-2942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036142179
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036.142179
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: