Provider Demographics
NPI:1871647925
Name:KWIECINSKI, PAWEL K (MD)
Entity Type:Individual
Prefix:MR
First Name:PAWEL
Middle Name:K
Last Name:KWIECINSKI
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 1:2781 MARDEN CT
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3400
Mailing Address - Country:US
Mailing Address - Phone:847-612-6584
Mailing Address - Fax:
Practice Address - Street 1:5356 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1513
Practice Address - Country:US
Practice Address - Phone:773-283-1881
Practice Address - Fax:773-283-2226
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617311OtherBLUE CROSS BLUE SHIELD
IL1617311OtherBLUE CROSS BLUE SHIELD
ILC42739Medicare UPIN