Healthcare Provider Details

I. General information

NPI: 1730162207
Provider Name (Legal Business Name): MATTHEW JOHN GLOWACKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W 95TH ST
EVERGREEN PARK IL
60805-2746
US

IV. Provider business mailing address

16221 W 159TH ST
LOCKPORT IL
60441-7959
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-4221
  • Fax: 708-422-4415
Mailing address:
  • Phone: 708-422-4221
  • Fax: 708-422-4415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-84982
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-64982
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036064982
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number020-01236
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: