=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447366133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STANLEY JOHN SZWALEK JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4062 W ROYAL DR
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-8965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-935-0338
-----------------------------------------------------
Fax | 231-935-0569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4062 W ROYAL DR
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-8965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-935-0338
-----------------------------------------------------
Fax | 231-935-0569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 4301030052
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------