MEDICARE: VIOLETTA MICKIEWICZ PA-C

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		IL

General Provider Information

NPI Number	:	1053427831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIOLETTA MICKIEWICZ PA-C

Provider Business Mailing Address
First Line	:	4501 WINCHESTER
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	773-250-0500
Fax Number	:	773-250-0497

Provider Business Practice Location Address
First Line	:	4501 N WINCHESTER AVE
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60640-5265
Country	:	US
Telephone Number	:	773-250-0500
Fax Number	:	773-250-0497

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	10/04/2007

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