Provider Demographics
NPI:1821238346
Name:KWAKBEAR P.C.
Entity Type:Organization
Organization Name:KWAKBEAR P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-636-7072
Mailing Address - Street 1:5011 CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8027
Mailing Address - Country:US
Mailing Address - Phone:630-636-7072
Mailing Address - Fax:
Practice Address - Street 1:5011 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8027
Practice Address - Country:US
Practice Address - Phone:630-636-7072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.120211208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty