Provider Demographics
NPI:1346541158
Name:MARY GAIL KWIECINSKI DPM P C
Entity Type:Organization
Organization Name:MARY GAIL KWIECINSKI DPM P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KWIECINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-816-3156
Mailing Address - Street 1:1870 W WINCHESTER RD STE 246
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5360
Mailing Address - Country:US
Mailing Address - Phone:847-816-3156
Mailing Address - Fax:847-816-9724
Practice Address - Street 1:1870 W WINCHESTER RD STE 246
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5360
Practice Address - Country:US
Practice Address - Phone:847-816-3156
Practice Address - Fax:847-816-9724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4933497OtherBLUE CROSS BLUE SHIELD
ILDR4991OtherMEDICARE RAILROAD
ILDR4991OtherMEDICARE RAILROAD
IL6608010001Medicare NSC