Provider Demographics
NPI:1003968157
Name:TRAUMA AND SURGICAL SPECIALISTS OF DUPAGE, LLC
Entity Type:Organization
Organization Name:TRAUMA AND SURGICAL SPECIALISTS OF DUPAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:IWANICKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:603-275-3892
Mailing Address - Street 1:3815 HIGHLAND AVE
Mailing Address - Street 2:TOWER 2, SUITE 107
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1500
Mailing Address - Country:US
Mailing Address - Phone:630-275-7800
Mailing Address - Fax:630-810-9240
Practice Address - Street 1:3815 HIGHLAND AVE
Practice Address - Street 2:TOWER 2, SUITE 107
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1500
Practice Address - Country:US
Practice Address - Phone:630-275-7800
Practice Address - Fax:630-810-9240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty