Provider Demographics
NPI:1619439809
Name:MACIUKIEWICZ, PHILIP SEBASTIAN (MD)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:SEBASTIAN
Last Name:MACIUKIEWICZ
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 1:2160 S FIRST AVENUE
Mailing Address - Street 2:BUILDING 103 ROOM 3107
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-9169
Mailing Address - Fax:708-216-1249
Practice Address - Street 1:2160 S FIRST AVENUE
Practice Address - Street 2:BUILDING 103 ROOM 3107
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-9169
Practice Address - Fax:708-216-1249
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2023-06-02
Deactivation Date:2019-11-07
Deactivation Code:
Reactivation Date:2019-11-27
Provider Licenses
StateLicense IDTaxonomies
IL125.074702207L00000X
IL036.158461208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology