=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558668863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOJCIECH GRZESKOWIAK M.D. LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2011
-----------------------------------------------------
Last Update Date | 02/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5370 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-631-0377
-----------------------------------------------------
Fax | 773-763-8756
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5370 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-631-0377
-----------------------------------------------------
Fax | 773-763-8756
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. WOJCIECH GRZESKOWIAK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-631-0377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036082984
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------