Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251H1200X | Hand | 056012898 | IL |
NPI | 1669943700 |
---|---|
Provider Name | Mark Anthony Pedziwiatr JR. |
First Address | Chicago, IL 60674-8634 |
Second Address | Naperville, IL 60540-8904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2018 |
Last Update Date | 11/02/2019 |