Provider Demographics
NPI:1386607356
Name:CIVILETTA-KALICH, WILLIAM BLAKE (PA)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:BLAKE
Last Name:CIVILETTA-KALICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:BLAKE
Other - Last Name:KALICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2361 PAYSPHERE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674
Mailing Address - Country:US
Mailing Address - Phone:414-325-7246
Mailing Address - Fax:414-325-3770
Practice Address - Street 1:2520 ELISHA AVENUE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099
Practice Address - Country:US
Practice Address - Phone:414-325-7246
Practice Address - Fax:414-325-3770
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1748023363A00000X
IL085.003749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000202870Medicare ID - Type Unspecified
Q18167Medicare UPIN