Provider Demographics
NPI:1396729554
Name:NIZIOLEK, ROMAN F (MD)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:F
Last Name:NIZIOLEK
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 1:603 W NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1321
Mailing Address - Country:US
Mailing Address - Phone:224-234-7642
Mailing Address - Fax:
Practice Address - Street 1:5025 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2772
Practice Address - Country:US
Practice Address - Phone:773-271-9040
Practice Address - Fax:773-989-1516
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-067726207R00000X
IL036067726207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH30716Medicare UPIN
ILK08789/357801Medicare ID - Type Unspecified
IL036-067726-2Medicaid