Provider Demographics
NPI:1528206984
Name:DUPAGE MEDICAL GROUP, LTD.
Entity Type:Organization
Organization Name:DUPAGE MEDICAL GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-790-1221
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE
Practice Address - Street 2:170
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4464
Practice Address - Country:US
Practice Address - Phone:630-322-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUPAGE MEDICAL GROUP, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-23
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-000124332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL785110OtherMEDICARE GROUP NUMBER
IL785110OtherMEDICARE GROUP NUMBER