Provider Demographics
NPI:1720079015
Name:MT VERNON NEUROLOGY, S.C.
Entity Type:Organization
Organization Name:MT VERNON NEUROLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TOMASZ
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOSIERKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-242-7350
Mailing Address - Street 1:PO BOX 2277
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0044
Mailing Address - Country:US
Mailing Address - Phone:618-242-7350
Mailing Address - Fax:618-242-7351
Practice Address - Street 1:2605 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2372
Practice Address - Country:US
Practice Address - Phone:618-242-7350
Practice Address - Fax:618-242-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty