1306056734 NPI number — PAWEL S. DUDEK, M.D., S.C.

Table of content: DR. MARK JOSEPH LENART MD (NPI 1003894759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306056734 NPI number — PAWEL S. DUDEK, M.D., S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAWEL S. DUDEK, M.D., S.C.
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:
1306056734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4840 N MARINE DR
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:
60640-7860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-654-1645
Provider Business Mailing Address Fax Number:
773-681-0289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4250 N MARINE DR
Provider Second Line Business Practice Location Address:
SUITE 236
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-404-0160
Provider Business Practice Location Address Fax Number:
773-404-9876
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUDEK
Authorized Official First Name:
PAWEL
Authorized Official Middle Name:
STANISLAW
Authorized Official Title or Position:
BOARD CERTIFIED PSYCHIATRIST
Authorized Official Telephone Number:
773-909-6269

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  036096327 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036096327 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 401806 . This is a "HARMONY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01635497 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2017926 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 404206 . This is a "VALUE OPTIONS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 180759 . This is a "COMPSYCH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 415428 . This is a "MHN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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