Provider Demographics
NPI:1275837734
Name:TERESA A. WANCZYK
Entity Type:Organization
Organization Name:TERESA A. WANCZYK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GROSVENOR
Authorized Official - Suffix:
Authorized Official - Credentials:MS,DO
Authorized Official - Phone:773-271-2900
Mailing Address - Street 1:3420 W PETERSON AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3418
Mailing Address - Country:US
Mailing Address - Phone:773-271-2900
Mailing Address - Fax:773-267-6113
Practice Address - Street 1:3420 W PETERSON AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3418
Practice Address - Country:US
Practice Address - Phone:773-271-2900
Practice Address - Fax:773-267-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065883204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
734260Medicare PIN