Provider Demographics
NPI:1548249071
Name:KAZANIWSKYJ, ANDREW L (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:L
Last Name:KAZANIWSKYJ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15505 E 127TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4433
Mailing Address - Country:US
Mailing Address - Phone:630-257-5400
Mailing Address - Fax:
Practice Address - Street 1:15505 E 127TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4433
Practice Address - Country:US
Practice Address - Phone:630-257-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061149Medicaid
687370Medicare ID - Type Unspecified
IL036061149Medicaid