Provider Demographics
NPI:1013638956
Name:WIELGOSZ, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:WIELGOSZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24157 S EDWIN DR
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-5210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12337 SOUTH, ILLINOIS ROUTE 59
Practice Address - Street 2:SUITE 119
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585
Practice Address - Country:US
Practice Address - Phone:815-267-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer