Basic Information
| Provider Information | |||||||||
| NPI: | 1568575629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CZERWONKA | ||||||||
| FirstName: | GRAZYNA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2290 | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542212290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202249 | ||||||||
| FaxNumber: | 9203203529 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542203712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202249 | ||||||||
| FaxNumber: | 9203203529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 05/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 39618 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 32633600 | 05 | WI | MEDICAID | 3908063950H8 | 01 | WI | BLUE CROSS BLUE SHIELD | OTHER | 050071232 | 01 | WI | MEDICARE RAILROAD | OTHER |