Provider Demographics
NPI:1124236971
Name:SIDOROWICZ, LUKASZ J
Entity type:Individual
Prefix:
First Name:LUKASZ
Middle Name:J
Last Name:SIDOROWICZ
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:PO BOX 56341
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-0341
Mailing Address - Country:US
Mailing Address - Phone:708-867-4949
Mailing Address - Fax:708-867-4981
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:773-502-4221
Practice Address - Fax:773-404-2086
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000043363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01637103OtherBLUE CROSS BLUE SHIELD OF IL