Provider Demographics
NPI:1104998780
Name:DRS. MATTANA AND KWIECINSKI
Entity type:Organization
Organization Name:DRS. MATTANA AND KWIECINSKI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KWIECINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-816-4711
Mailing Address - Street 1:250 CENTER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1582
Mailing Address - Country:US
Mailing Address - Phone:847-816-4711
Mailing Address - Fax:847-247-1158
Practice Address - Street 1:250 CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1582
Practice Address - Country:US
Practice Address - Phone:847-816-4711
Practice Address - Fax:847-247-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
016004013213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDP7858OtherRAILROAD MEDICARE
IL0004932354OtherBLUE CROSS BLUE SHIELD
IL212569Medicare ID - Type Unspecified
IL6205970001Medicare NSC