Provider Demographics
NPI:1700018538
Name:PODZAMSKY MEDICAL SERVICES
Entity Type:Organization
Organization Name:PODZAMSKY MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PODZAMSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:309-432-2441
Mailing Address - Street 1:120 E. 7TH ST.
Mailing Address - Street 2:
Mailing Address - City:MINONK
Mailing Address - State:IL
Mailing Address - Zip Code:61760
Mailing Address - Country:US
Mailing Address - Phone:309-432-2515
Mailing Address - Fax:309-432-2160
Practice Address - Street 1:301 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2969
Practice Address - Country:US
Practice Address - Phone:815-673-2441
Practice Address - Fax:815-672-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055223305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055223Medicaid
IL1225013840OtherNPI
IL645950OtherPTAN - MINONK ILLINOIS LOCATION OF SERVICE
IL645951OtherPTAN - STREATOR ILLINOIS LOCATION OF SERVICE
IL645951OtherPTAN - STREATOR ILLINOIS LOCATION OF SERVICE