Provider Demographics
NPI:1073792545
Name:ALICJA BARBARA POLESZAK S.C.
Entity Type:Organization
Organization Name:ALICJA BARBARA POLESZAK S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICJA
Authorized Official - Middle Name:B
Authorized Official - Last Name:POLESZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-456-3200
Mailing Address - Street 1:7740 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-4124
Mailing Address - Country:US
Mailing Address - Phone:708-456-3200
Mailing Address - Fax:708-456-3427
Practice Address - Street 1:7740 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-4124
Practice Address - Country:US
Practice Address - Phone:708-456-3200
Practice Address - Fax:708-456-3427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-100964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100964Medicaid
IL209523Medicare PIN
IL036100964Medicaid