Healthcare Provider Details

I. General information

NPI: 1578822870
Provider Name (Legal Business Name): MR. ANDREW STODOLKIEWICZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E JEFFERSON ST
MACOMB IL
61455-2312
US

IV. Provider business mailing address

2960 CHARTRES ST P.O. BOX 1488
LA SALLE IL
61301-1097
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-2191
  • Fax: 309-836-2118
Mailing address:
  • Phone: 815-224-1610
  • Fax: 815-223-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: