Healthcare Provider Details

I. General information

NPI: 1487922753
Provider Name (Legal Business Name): MICHAL KOLODZIEJ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W HINTZ RD
WHEELING IL
60090-5501
US

IV. Provider business mailing address

13 E STONEGATE DR
PROSPECT HEIGHTS IL
60070-1054
US

V. Phone/Fax

Practice location:
  • Phone: 847-537-7474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.005143
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: