Provider Demographics
NPI:1114952504
Name:KOWALCZYK BUDZIAKOWSKA, BEATA ZOSIA (MD)
Entity Type:Individual
Prefix:
First Name:BEATA
Middle Name:ZOSIA
Last Name:KOWALCZYK BUDZIAKOWSKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-823-3583
Mailing Address - Fax:
Practice Address - Street 1:3115 N HARLEM
Practice Address - Street 2:STE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634
Practice Address - Country:US
Practice Address - Phone:773-889-0355
Practice Address - Fax:773-889-0803
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H58860Medicare UPIN
IL201583Medicare ID - Type Unspecified