Healthcare Provider Details

I. General information

NPI: 1871971929
Provider Name (Legal Business Name): AIDAS BUZELIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 183RD ST
HOMEWOOD IL
60430-3134
US

IV. Provider business mailing address

843 CRAMER CT
WILLOWBROOK IL
60527-5324
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-5556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number227005737
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: