Provider Demographics
NPI:1417112954
Name:MAREK WALCZYK MD SC
Entity Type:Organization
Organization Name:MAREK WALCZYK MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-224-8840
Mailing Address - Street 1:1300 HIGGINS RD
Mailing Address - Street 2:212
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-5743
Mailing Address - Country:US
Mailing Address - Phone:847-823-5151
Mailing Address - Fax:
Practice Address - Street 1:1300 HIGGINS RD
Practice Address - Street 2:212
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5743
Practice Address - Country:US
Practice Address - Phone:847-823-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1632658OtherBCBS
IL020363109Medicaid
ILH66423Medicare UPIN
IL202328Medicare PIN