Provider Demographics
NPI:1003845561
Name:IWANICKI, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:IWANICKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3815 HIGHLAND AVE
Practice Address - Street 2:TOWER 2, SUITE 107
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1500
Practice Address - Country:US
Practice Address - Phone:630-275-7800
Practice Address - Fax:630-810-9240
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1053992086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH75064Medicare UPIN