Provider Demographics
NPI:1831188317
Name:REWERSKI, STANISLAW (MD)
Entity type:Individual
Prefix:DR
First Name:STANISLAW
Middle Name:
Last Name:REWERSKI
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 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-285-5629
Mailing Address - Fax:815-285-5634
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3116
Practice Address - Country:US
Practice Address - Phone:815-285-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084832207Q00000X
IL036084832208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34604400Medicaid
IL036084832Medicaid
IL036084832Medicaid
E49119Medicare UPIN