Healthcare Provider Details

I. General information

NPI: 1457342610
Provider Name (Legal Business Name): MICHAEL LOUIS RADZIENDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19310 S HALSTED ST
GLENWOOD IL
60425-1562
US

IV. Provider business mailing address

19310 S HALSTED ST
GLENWOOD IL
60425-1562
US

V. Phone/Fax

Practice location:
  • Phone: 708-300-3132
  • Fax: 773-790-4034
Mailing address:
  • Phone: 708-300-3132
  • Fax: 773-790-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01060676A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number50075
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036095779
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: