MEDICARE: WIESLAW WLODARSKI PT

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	225100000X	Physical Therapist	070-006747	IL

General Provider Information

NPI Number	:	1689855330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WIESLAW WLODARSKI PT

Provider Business Mailing Address
First Line	:	4005 N NASHVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1428
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 N NASHVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1428
Country	:	US
Telephone Number	:	847-414-0481
Fax Number	:	773-777-9872

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

Provider Enumeration Date	:	11/23/2007
Last Update Date	:	09/24/2019

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