Healthcare Provider Details

I. General information

NPI: 1386607356
Provider Name (Legal Business Name): WILLIAM BLAKE CIVILETTA-KALICH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WILLIAM BLAKE KALICH PAC

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVENUE
ZION IL
60099
US

IV. Provider business mailing address

2361 PAYSPHERE CIRCLE
CHICAGO IL
60674
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7246
  • Fax: 414-325-3770
Mailing address:
  • Phone: 414-325-7246
  • Fax: 414-325-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1748023
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.003749
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: