Provider Demographics
NPI:1619363645
Name:SIWOSKI, MARK-VICTOR
Entity Type:Individual
Prefix:
First Name:MARK-VICTOR
Middle Name:
Last Name:SIWOSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2850
Mailing Address - Country:US
Mailing Address - Phone:630-742-8506
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5377
Practice Address - Country:US
Practice Address - Phone:269-341-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI43015036052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program