1588809008 NPI number — DUPAGE MEDICAL GROUP, LTD

Table of content: (NPI 1588809008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588809008 NPI number — DUPAGE MEDICAL GROUP, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUPAGE MEDICAL GROUP, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588809008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 713260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-1260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-469-9200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 N ELM ST
Provider Second Line Business Practice Location Address:
103
Provider Business Practice Location Address City Name:
HINSDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60521-3635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-286-5060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MERRICK
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
630-790-1221

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  042000124 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , with the licence number: 042000124 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 785110 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 568660 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".