Provider Demographics
NPI:1508163031
Name:WALDEMAR MYSIAK MD SC
Entity Type:Organization
Organization Name:WALDEMAR MYSIAK MD SC
Other - Org Name:FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALDEMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MYSIAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-281-1100
Mailing Address - Street 1:755 S MILWAUKEE AVE STE 261
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3266
Mailing Address - Country:US
Mailing Address - Phone:847-281-1100
Mailing Address - Fax:847-281-1300
Practice Address - Street 1:755 S MILWAUKEE AVE STE 261
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3266
Practice Address - Country:US
Practice Address - Phone:847-281-1100
Practice Address - Fax:847-281-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099938Medicaid
IL036099938Medicaid
205137Medicare PIN