Provider Demographics
NPI:1629032958
Name:KACZMAREK, GREGORY D (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:KACZMAREK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4905 OLD ORCHARD CTR
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1425
Mailing Address - Country:US
Mailing Address - Phone:847-679-6707
Mailing Address - Fax:847-679-6721
Practice Address - Street 1:4905 OLD ORCHARD CTR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1425
Practice Address - Country:US
Practice Address - Phone:847-679-6707
Practice Address - Fax:847-679-6721
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036081697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603901OtherBLUE CROSS BLUE SHIELD
IL943230Medicare PIN
ILE74866Medicare UPIN