=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528399359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDCITY SPINE AND ORTHO REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2010
-----------------------------------------------------
Last Update Date | 03/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4332 S PULASKI RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-969-4777
-----------------------------------------------------
Fax | 773-634-8295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4332 S PULASKI RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-969-4777
-----------------------------------------------------
Fax | 773-634-8295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TOM DZIELAWSKI
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 773-969-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------