Basic Information
| Provider Information | |||||||||
| NPI: | 1467827907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCINEK | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1340 CHARLES ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796965888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | 209013633 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 206147 | 01 | IL | MEDICARE PTAN (GROUP) | OTHER | F400268415 | 01 | IL | MEDICARE PTAN (INDIVIDUAL) | OTHER |