Provider Demographics
NPI:1033744388
Name:BACZEK, MATEUSZ
Entity Type:Individual
Prefix:
First Name:MATEUSZ
Middle Name:
Last Name:BACZEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39161 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60099-3729
Mailing Address - Country:US
Mailing Address - Phone:847-746-6230
Mailing Address - Fax:
Practice Address - Street 1:39161 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099-3729
Practice Address - Country:US
Practice Address - Phone:847-746-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19133-40183500000X
IL051.300528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist