Basic Information
Provider Information | |||||||||
NPI: | 1801852322 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BACH | ||||||||
FirstName: | MALGORZATA | ||||||||
MiddleName: | KRYSTYNA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OCZKO-WALKER | ||||||||
OtherFirstName: | MALGORZATA | ||||||||
OtherMiddleName: | KRYSTYNA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 22285 PEPPER RD | ||||||||
Address2: | STE 401 | ||||||||
City: | LAKE BARRINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 60010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478826604 | ||||||||
FaxNumber: | 8478826228 | ||||||||
Practice Location | |||||||||
Address1: | 22285 PEPPER RD | ||||||||
Address2: | STE 401 | ||||||||
City: | LAKE BARRINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 60010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478826604 | ||||||||
FaxNumber: | 8478826228 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2006 | ||||||||
LastUpdateDate: | 12/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036115194 | IL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 036115194 | 05 | IL |   | MEDICAID |