MEDICARE: BOHDAN ASKOLD IWANETZ MD

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	208600000X	Surgery Physician		IL

General Provider Information

NPI Number	:	1013916089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOHDAN ASKOLD IWANETZ MD

Provider Business Mailing Address
First Line	:	713 E 142ND ST
Second Line	:
City	:	DOLTON
State	:	IL
Zip	:	60419-1062
Country	:	US
Telephone Number	:	708-841-1121
Fax Number	:	708-841-6976

Provider Business Practice Location Address
First Line	:	713 E 142ND ST
Second Line	:
City	:	DOLTON
State	:	IL
Zip	:	60419-1062
Country	:	US
Telephone Number	:	708-841-1121
Fax Number	:	708-841-6976

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/08/2007

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