Provider Demographics
NPI:1285732198
Name:WANCZYK, TERESA A (DO)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:A
Last Name:WANCZYK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:A
Other - Last Name:GROSVENOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:6234 N ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1402
Mailing Address - Country:US
Mailing Address - Phone:773-271-2900
Mailing Address - Fax:773-267-6113
Practice Address - Street 1:3414 W PETERSON AVE
Practice Address - Street 2:STE. D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3452
Practice Address - Country:US
Practice Address - Phone:773-271-2900
Practice Address - Fax:773-267-6113
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065883204D00000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065883Medicaid
IL036065883Medicaid