1366581811 NPI number — DUPAGE META-VASCULAR MEDICINE PC

Table of content: (NPI 1366581811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366581811 NPI number — DUPAGE META-VASCULAR MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUPAGE META-VASCULAR MEDICINE PC
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:
1366581811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 S GARY AVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BLOOMINGDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60108-2228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-893-2190
Provider Business Mailing Address Fax Number:
630-307-8716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 S GARY AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BLOOMINGDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60108-2228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-893-2190
Provider Business Practice Location Address Fax Number:
630-307-8716
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOSIEK
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
MARY
Authorized Official Title or Position:
RN/PRACTICE MANAGER
Authorized Official Telephone Number:
630-893-2190

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  036047587 , 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: 2232209 . This is a "BLUE SHIELD NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1366581811 . This is a "GROUP NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00843099 . This is a "RAIL ROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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