Provider Demographics
NPI:1396711370
Name:KALISIAK, ROGER ALLAN (MS,ATC)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:ALLAN
Last Name:KALISIAK
Suffix:
Gender:M
Credentials:MS,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 PATRIOT LN
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60195-1829
Mailing Address - Country:US
Mailing Address - Phone:847-991-1468
Mailing Address - Fax:
Practice Address - Street 1:1100 W HIGGINS RD
Practice Address - Street 2:HOFFMAN ESTATES HIGH SCHOOL
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60195-3050
Practice Address - Country:US
Practice Address - Phone:847-755-5790
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist