=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508269358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEADACHE CENTER OF CHICAGO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6317 FAIRVIEW AVE STE 3
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-852-6666
-----------------------------------------------------
Fax | 630-968-0958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6317 FAIRVIEW AVE STE 3
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-852-6666
-----------------------------------------------------
Fax | 630-968-0958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS WILLIAM BRZOSTOWSKI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 630-852-6666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019025308
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019021165
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------