Basic Information
| Provider Information | |||||||||
| NPI: | 1962676585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROTAZIUK | ||||||||
| FirstName: | LILIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16519 S RTE 59 | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605862606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306465020 | ||||||||
| FaxNumber: | 6306465025 | ||||||||
| Practice Location | |||||||||
| Address1: | 16519 S RTE 59 | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605862606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306465020 | ||||||||
| FaxNumber: | 6306465025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036118881 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1962676585 1 | 05 | IL | MEDICAID |