Provider Demographics
NPI:1013188598
Name:PODLASEK, WIESLAW J (MD)
Entity Type:Individual
Prefix:DR
First Name:WIESLAW
Middle Name:J
Last Name:PODLASEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 HARLEM ROAD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-654-5342
Practice Address - Street 1:2202 HARLEM ROAD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-654-5342
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085145207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00911925OtherRAILROAD MEDICARE
IL036085145Medicaid
R00596Medicare PIN
IL036085145Medicaid
R00596/610900Medicare PIN