Provider Demographics
NPI:1366547234
Name:KWIECINSKI, MARY GAIL H (DPM)
Entity type:Individual
Prefix:DR
First Name:MARY GAIL
Middle Name:H
Last Name:KWIECINSKI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 W WINCHESTER RD STE 246
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5360
Mailing Address - Country:US
Mailing Address - Phone:847-816-3156
Mailing Address - Fax:847-816-9724
Practice Address - Street 1:1870 W WINCHESTER RD STE 246
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5360
Practice Address - Country:US
Practice Address - Phone:847-816-3156
Practice Address - Fax:847-816-9724
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004013213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00788908OtherMEDICARE RAILROAD
IL480006294OtherMEDICARE RAILROAD
ILP00938475OtherMEDICARE RAILROAD
IL016004013Medicaid
ILP00938475OtherMEDICARE RAILROAD
ILK44732Medicare PIN
IL773040Medicare PIN
ILT38859Medicare UPIN
ILIL5106Medicare PIN
ILP00788908OtherMEDICARE RAILROAD
IL215591Medicare PIN