Healthcare Provider Details

I. General information

NPI: 1235188533
Provider Name (Legal Business Name): MARK A TOMCZAK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18221 TORRENCE AVE SUITE 1B
LANSING IL
60438-2870
US

IV. Provider business mailing address

18221 TORRENCE AVE
LANSING IL
60438-2870
US

V. Phone/Fax

Practice location:
  • Phone: 708-895-9450
  • Fax: 708-895-9455
Mailing address:
  • Phone: 708-895-9450
  • Fax: 708-895-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28118620A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number209002567
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: