Provider Demographics
NPI:1720070170
Name:JELCZ, MARION G (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:G
Last Name:JELCZ
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 1:2801 LAKESIDE DR STE 209
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1271
Mailing Address - Country:US
Mailing Address - Phone:847-562-1410
Mailing Address - Fax:847-562-0830
Practice Address - Street 1:4905 OLD ORCHARD CTR STE 200
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1462
Practice Address - Country:US
Practice Address - Phone:847-869-5800
Practice Address - Fax:847-869-9315
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082775207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK45088Medicare PIN
ILF32814Medicare UPIN
ILK45087Medicare PIN