Provider Demographics
NPI:1417055922
Name:GARWACKI, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:GARWACKI
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 1:100 NE RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1919
Mailing Address - Country:US
Mailing Address - Phone:309-624-8500
Mailing Address - Fax:309-655-8552
Practice Address - Street 1:100 NE RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1919
Practice Address - Country:US
Practice Address - Phone:309-624-8500
Practice Address - Fax:309-655-8552
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL91916Medicare ID - Type UnspecifiedINDIVIDUAL #
ILL39300Medicare ID - Type UnspecifiedINDIVIDUAL #
IL89409Medicare UPIN
IL113001372 - CA4079Medicare ID - Type UnspecifiedRR
IL846900Medicare ID - Type UnspecifiedGROUP #