Provider Demographics
NPI:1548212020
Name:SKOCZELAS, PHILLIP A (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:A
Last Name:SKOCZELAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 N PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2772
Mailing Address - Country:US
Mailing Address - Phone:773-989-1357
Mailing Address - Fax:773-989-5406
Practice Address - Street 1:5025 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2772
Practice Address - Country:US
Practice Address - Phone:773-989-1357
Practice Address - Fax:773-989-5406
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057792208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057792-3Medicaid
ILC44435Medicare UPIN
ILK27903Medicare PIN
IL637510Medicare ID - Type Unspecified