Provider Demographics
NPI:1184638009
Name:SAWICKI, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SAWICKI
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 1:2265 W ALTORFER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1807
Mailing Address - Country:US
Mailing Address - Phone:309-683-7700
Mailing Address - Fax:309-683-7752
Practice Address - Street 1:2265 W ALTORFER DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1807
Practice Address - Country:US
Practice Address - Phone:309-683-7700
Practice Address - Fax:309-683-7752
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069063207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03609063Medicaid
809840OtherGROUP #
809840OtherGROUP #
809840065Medicare PIN
ILC47664Medicare UPIN
IL03609063Medicaid
IL833100Medicare ID - Type UnspecifiedGROUP #
ILL27019Medicare ID - Type UnspecifiedINDIVIDUAL #