Healthcare Provider Details

I. General information

NPI: 1679772479
Provider Name (Legal Business Name): MIROSLAW WALO, MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 WINNETKA AVE
NORTHFIELD IL
60093-3318
US

IV. Provider business mailing address

4905 OLD ORCHARD CTR STE 428
SKOKIE IL
60077
US

V. Phone/Fax

Practice location:
  • Phone: 847-324-4300
  • Fax: 847-324-4303
Mailing address:
  • Phone: 847-324-4300
  • Fax: 847-324-4303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number042618878
License Number StateIL

VIII. Authorized Official

Name: DR. MIROSLAW JAN WALO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-324-4300