Provider Demographics
NPI:1629334305
Name:RONALD TUPIK D O LTD
Entity Type:Organization
Organization Name:RONALD TUPIK D O LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:TUPIK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-485-9160
Mailing Address - Street 1:500 E MAPLE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2908
Mailing Address - Country:US
Mailing Address - Phone:815-485-9160
Mailing Address - Fax:815-485-9176
Practice Address - Street 1:500 E MAPLE
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2908
Practice Address - Country:US
Practice Address - Phone:815-485-9160
Practice Address - Fax:815-485-9176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL618510Medicare PIN
ILC44029Medicare UPIN