Provider Demographics
NPI:1558546952
Name:FOX VALLEY ADULT AND PEDIATRIC MEDICINE PC
Entity Type:Organization
Organization Name:FOX VALLEY ADULT AND PEDIATRIC MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ZBIGNIEW
Authorized Official - Middle Name:MARIAN
Authorized Official - Last Name:CIECHANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-513-0298
Mailing Address - Street 1:2020 DEAN ST. STE G
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1665
Mailing Address - Country:US
Mailing Address - Phone:630-513-0298
Mailing Address - Fax:
Practice Address - Street 1:2020 DEAN ST. STE G
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1665
Practice Address - Country:US
Practice Address - Phone:630-513-0298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532182OtherBLUE CROSS BLUE SHIELD IL
E94586OtherUPIN
IL209416Medicare PIN