Healthcare Provider Details

I. General information

NPI: 1558546952
Provider Name (Legal Business Name): FOX VALLEY ADULT AND PEDIATRIC MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 DEAN ST. STE G
ST. CHARLES IL
60174-1665
US

IV. Provider business mailing address

2020 DEAN ST. STE G
ST. CHARLES IL
60174-1665
US

V. Phone/Fax

Practice location:
  • Phone: 630-513-0298
  • Fax:
Mailing address:
  • Phone: 630-513-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ZBIGNIEW MARIAN CIECHANOWSKI
Title or Position: CEO
Credential: M.D.
Phone: 630-513-0298