Provider Demographics
NPI:1710097779
Name:KMICIKEWYCZ, ALEXANDER WOLODYMYR (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:WOLODYMYR
Last Name:KMICIKEWYCZ
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 1:12622 SOUTH HARLEM AVENUE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1428
Mailing Address - Country:US
Mailing Address - Phone:708-923-9610
Mailing Address - Fax:708-923-9613
Practice Address - Street 1:12622 SOUTH HARLEM AVENUE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1428
Practice Address - Country:US
Practice Address - Phone:708-923-9610
Practice Address - Fax:708-923-9613
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31601176OtherBLUE CROSS BLUE SHIELD IL
IL749170Medicare PIN
C47670Medicare UPIN