Provider Demographics
NPI:1255391116
Name:WALCZYNSKI, ANN (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:WALCZYNSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 DEMPSTER
Mailing Address - Street 2:STE 490
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1120
Mailing Address - Country:US
Mailing Address - Phone:773-792-0088
Mailing Address - Fax:773-792-0054
Practice Address - Street 1:1875 DEMPSTER
Practice Address - Street 2:STE 490
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1120
Practice Address - Country:US
Practice Address - Phone:773-792-0088
Practice Address - Fax:773-792-0054
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360497322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049732Medicaid
C42187Medicare UPIN
IL484821Medicare ID - Type Unspecified