MEDICARE: DR. JANUSZ P SRODULSKI 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	207R00000X	Internal Medicine Physician	036062671	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036062671	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1467478701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANUSZ P SRODULSKI MD

Provider Business Mailing Address
First Line	:	1200 W ALGONQUIN RD BLDG M
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-7373
Country	:	US
Telephone Number	:	847-618-0121
Fax Number	:	847-618-0134

Provider Business Practice Location Address
First Line	:	1200 W ALGONQUIN RD BLDG M
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-7373
Country	:	US
Telephone Number	:	847-618-0121
Fax Number	:	847-618-0134

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	10/17/2022

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