Provider Demographics
NPI:1609921170
Name:WESTERN DUPAGE OBSTETRICS & GYNECOLOGY SC
Entity Type:Organization
Organization Name:WESTERN DUPAGE OBSTETRICS & GYNECOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BANUELOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-810-0777
Mailing Address - Street 1:3540 SEVEN BRIDGES DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1222
Mailing Address - Country:US
Mailing Address - Phone:630-810-0777
Mailing Address - Fax:630-810-0395
Practice Address - Street 1:3540 SEVEN BRIDGES DR STE 200
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1222
Practice Address - Country:US
Practice Address - Phone:630-810-0777
Practice Address - Fax:630-810-0395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2201686OtherBCBS ILLINOIS PROVIDER #