Provider Demographics
NPI:1891781639
Name:BOLANOWSKI, MARYBETH (PA)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:BOLANOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1801 S HIGHLAND AVE STE 220
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4932
Practice Address - Country:US
Practice Address - Phone:630-790-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001424363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL970023229OtherRAILROAD MEDICARE
IL085001424Medicaid
ILK52382Medicare PIN
IL085001424Medicaid
ILK52383Medicare PIN
IL970023229OtherRAILROAD MEDICARE