Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036070574 | IL |
Y | 208600000X | Surgeon | 036070574 | IL |
NPI | 1003840257 |
---|---|
Provider Name | Jay Prystowsky |
First Address | Chicago, IL 60611-4546 |
Second Address | Chicago, IL 60611-4546 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 12/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036070574 | (05) | IL |
E18338 | (02) |