Provider Demographics
NPI:1730254004
Name:MIERZWA, WITOLD JAN (PT)
Entity type:Individual
Prefix:
First Name:WITOLD
Middle Name:JAN
Last Name:MIERZWA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 S KEDZIE AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803
Mailing Address - Country:US
Mailing Address - Phone:708-371-6441
Mailing Address - Fax:708-371-6429
Practice Address - Street 1:11600 S KEDZIE AVE
Practice Address - Street 2:SUITE K
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803
Practice Address - Country:US
Practice Address - Phone:708-371-6441
Practice Address - Fax:708-371-6429
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18503Medicare ID - Type Unspecified