Basic Information
Provider Information | |||||||||
NPI: | 1447200563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KISIELIUS | ||||||||
FirstName: | PETRAS | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4201 WINFIELD RD FL 4 | ||||||||
Address2: |   | ||||||||
City: | WARRENVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605554025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3312216377 | ||||||||
FaxNumber: | 3312212357 | ||||||||
Practice Location | |||||||||
Address1: | 1200 S YORK ST STE 2000 | ||||||||
Address2: |   | ||||||||
City: | ELMHURST | ||||||||
State: | IL | ||||||||
PostalCode: | 601265634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3312219004 | ||||||||
FaxNumber: | 3312212748 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 06/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036068731 | IL | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.