MEDICARE: WIESLAW ROBERT DYBOWSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	238000076	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01637103	OTHER	IL	BLUE CROSS BLUE SHIELD OF IL

General Provider Information

NPI Number	:	1013124403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WIESLAW ROBERT DYBOWSKI

Provider Business Mailing Address
First Line	:	PO BOX 56341
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-0341
Country	:	US
Telephone Number	:	708-867-4949
Fax Number	:	708-867-4981

Provider Business Practice Location Address
First Line	:	3249 OAK PARK AVE
Second Line	:
City	:	BERWYN
State	:	IL
Zip	:	60402-3429
Country	:	US
Telephone Number	:	773-502-4221
Fax Number	:	773-404-2086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	02/08/2026

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