Healthcare Provider Details

I. General information

NPI: 1073597894
Provider Name (Legal Business Name): MARKO J JACHTOROWYCZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5747 DEMPSTER ST SUITE 100
MORTON GROVE IL
60053-3056
US

IV. Provider business mailing address

5747 DEMPSTER ST SUITE 100
MORTON GROVE IL
60053-3056
US

V. Phone/Fax

Practice location:
  • Phone: 847-663-1030
  • Fax: 847-663-1039
Mailing address:
  • Phone: 847-663-1030
  • Fax: 847-663-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number036080243
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036080243
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: