Provider Demographics
NPI:1659631273
Name:JOSEPH Z. PUDLO, M.D., S.C.
Entity Type:Organization
Organization Name:JOSEPH Z. PUDLO, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:Z
Authorized Official - Last Name:PUDLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-631-2442
Mailing Address - Street 1:6145 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-3804
Mailing Address - Country:US
Mailing Address - Phone:773-631-2442
Mailing Address - Fax:773-631-6530
Practice Address - Street 1:6145 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-3804
Practice Address - Country:US
Practice Address - Phone:773-631-2442
Practice Address - Fax:773-631-6530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072100207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL775130Medicare UPIN