Provider Demographics
NPI:1730162207
Name:GLOWACKI, MATTHEW JOHN (DO)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:GLOWACKI
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 1:16221 W 159TH ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-7959
Mailing Address - Country:US
Mailing Address - Phone:708-422-4221
Mailing Address - Fax:708-422-4415
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2746
Practice Address - Country:US
Practice Address - Phone:708-422-4221
Practice Address - Fax:708-422-4415
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064982207PE0004X
IN020-01236207R00000X
IL036-84982207P00000X
IL036-64982207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15624Medicare UPIN