Provider Demographics
NPI:1609046317
Name:COSMETIC AND PLASTIC SURGERY OF NORTHWEST INDIANA PC
Entity Type:Organization
Organization Name:COSMETIC AND PLASTIC SURGERY OF NORTHWEST INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:MALCZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-945-0669
Mailing Address - Street 1:7865 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6665
Mailing Address - Country:US
Mailing Address - Phone:219-945-0669
Mailing Address - Fax:219-945-5669
Practice Address - Street 1:7865 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6665
Practice Address - Country:US
Practice Address - Phone:219-945-0669
Practice Address - Fax:219-945-5669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COSMETIC AND PLASTIC SURGERY OF NORTHWEST INDIANA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-10
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043550A174400000X
01043550A208200000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200025060AMedicaid
IN200253570LMedicaid
IN200025060AMedicaid
IN200253570LMedicaid