=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356575690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CHWAJOL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2009
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 W TAYLOR ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 886-600-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1350 N WELLS ST APT. F 203
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-675-2670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | 036.123878
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------