Provider Demographics
NPI:1346682614
Name:POLISH AMERICAN ASSOCIATION
Entity Type:Organization
Organization Name:POLISH AMERICAN ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-427-6317
Mailing Address - Street 1:3834 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3622
Mailing Address - Country:US
Mailing Address - Phone:773-282-8206
Mailing Address - Fax:773-282-1324
Practice Address - Street 1:3834 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3622
Practice Address - Country:US
Practice Address - Phone:773-282-8206
Practice Address - Fax:773-282-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========912Medicare PIN