Healthcare Provider Details

I. General information

NPI: 1093261661
Provider Name (Legal Business Name): MR. PAWEL SKORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 03/07/2020
Certification Date: 03/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 S SOUTHPORT RD
MUNDELEIN IL
60060-4563
US

IV. Provider business mailing address

207 S SOUTHPORT RD
MUNDELEIN IL
60060-4563
US

V. Phone/Fax

Practice location:
  • Phone: 847-345-0649
  • Fax:
Mailing address:
  • Phone: 847-345-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.006883
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: