MEDICARE: PAWEL K KWIECINSKI MD LTD

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	207Q00000X	Family Medicine Physician	036069086	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	730521	OTHER	IL	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1617311	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1124215223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAWEL K KWIECINSKI MD LTD

Provider Business Mailing Address
First Line	:	5356 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1513
Country	:	US
Telephone Number	:	773-283-1881
Fax Number	:

Provider Business Practice Location Address
First Line	:	5356 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1513
Country	:	US
Telephone Number	:	773-283-1881
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAWEL K KWIECINSKI
Credential	:	M.D.
Telephone Number	:	773-283-1881

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/02/2007

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