Provider Demographics
NPI:1558604504
Name:DUPAGE MEDICAL GROUP LTD
Entity Type:Organization
Organization Name:DUPAGE MEDICAL GROUP LTD
Other - Org Name:THE PHARMACY OF DU PAGE MEDICAL GROUP
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:630-790-1221
Mailing Address - Street 1:430 WARRENVILLE RD
Mailing Address - Street 2:215
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 WARRENVILLE RD
Practice Address - Street 2:215
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1348
Practice Address - Country:US
Practice Address - Phone:630-539-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054018228333600000X, 3336C0002X, 3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6180250022Medicare NSC