Basic Information
Provider Information | |||||||||
NPI: | 1386607356 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CIVILETTA-KALICH | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | BLAKE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KALICH | ||||||||
OtherFirstName: | WILLIAM | ||||||||
OtherMiddleName: | BLAKE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2361 PAYSPHERE CIRCLE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4143257246 | ||||||||
FaxNumber: | 4143253770 | ||||||||
Practice Location | |||||||||
Address1: | 2520 ELISHA AVENUE | ||||||||
Address2: |   | ||||||||
City: | ZION | ||||||||
State: | IL | ||||||||
PostalCode: | 60099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4143257246 | ||||||||
FaxNumber: | 4143253770 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2006 | ||||||||
LastUpdateDate: | 10/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1748023 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 085.003749 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.