MEDICARE: DR. TERESA A. WANCZYK DO

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	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	036-065883	IL
2	208000000X	Pediatrics Physician	036-065883	IL
3	208D00000X	General Practice Physician	036-065883	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285732198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERESA A. WANCZYK DO

Provider Business Mailing Address
First Line	:	6234 N ALBANY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1402
Country	:	US
Telephone Number	:	773-271-2900
Fax Number	:	773-267-6113

Provider Business Practice Location Address
First Line	:	3414 W PETERSON AVE
Second Line	:	STE. D
City	:	CHICAGO
State	:	IL
Zip	:	60659-3452
Country	:	US
Telephone Number	:	773-271-2900
Fax Number	:	773-267-6113

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	06/25/2020

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