Provider Demographics
NPI:1033347166
Name:PIWKO, RADOMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:RADOMIR
Middle Name:
Last Name:PIWKO
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 1:5200 COMMERCE CROSSING
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-975-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056990207R00000X
IN01071086A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201074520Medicaid
IN000000773791OtherANTHEM PROVIDER NUMBER
IN815500001Medicare PIN
INP01094828Medicare PIN