Provider Demographics
NPI:1346277597
Name:RADZIWIECKI, THADDEUS F (DPM)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:F
Last Name:RADZIWIECKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:
Other - Last Name:RADZIWIECKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:3641 RIDGE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2080
Mailing Address - Country:US
Mailing Address - Phone:219-838-4000
Mailing Address - Fax:219-838-4387
Practice Address - Street 1:3641 RIDGE RD
Practice Address - Street 2:SUITE 6
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2080
Practice Address - Country:US
Practice Address - Phone:219-838-4000
Practice Address - Fax:219-838-4387
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000594A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480026572OtherRAILROAD MEDICARE
IN000000080130OtherANTHEM BLUE CROSS SHIELD
IN5622190001OtherMEDICARE DMEPOS
480026572OtherRAILROAD MEDICARE
IN000000080130OtherANTHEM BLUE CROSS SHIELD