Basic Information
| Provider Information | |||||||||
| NPI: | 1891781639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLANOWSKI | ||||||||
| FirstName: | MARYBETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606743698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 S HIGHLAND AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601484932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307901872 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085001424 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085001424 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970023229 | 01 | IL | RAILROAD MEDICARE | OTHER | 085001424 | 05 | IL | MEDICAID |