Provider Demographics
NPI:1679748222
Name:MAREK WALCZYK MD,SC
Entity Type:Organization
Organization Name:MAREK WALCZYK MD,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-647-7550
Mailing Address - Street 1:1820 RIDGE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1760
Mailing Address - Country:US
Mailing Address - Phone:708-647-7550
Mailing Address - Fax:708-647-7564
Practice Address - Street 1:1820 RIDGE RD
Practice Address - Street 2:STE: 104
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1760
Practice Address - Country:US
Practice Address - Phone:708-647-7550
Practice Address - Fax:708-647-7564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107779261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107779Medicaid