1043271554 NPI number — PAWEL S DUDEK M.D.

Table of content: PAWEL S DUDEK M.D. (NPI 1043271554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043271554 NPI number — PAWEL S DUDEK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUDEK
Provider First Name:
PAWEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUDEK
Provider Other First Name:
PAWEL
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D., S.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043271554
Entity Type Code:
Individual
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:
773-681-9876

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:
04/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

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 IL" 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: 2017926 . This is a "CIGNA" 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".
  • Identifier: 180759 . This is a "COMPSYCH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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