Provider Demographics
NPI:1700839230
Name:DUPAGE MEDICAL GROUP, LTD
Entity Type:Organization
Organization Name:DUPAGE MEDICAL GROUP, LTD
Other - Org Name:DUPAGE MEDICAL GROUP, LTD
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:MD
Authorized Official - Phone:630-790-1221
Mailing Address - Street 1:2320 HIGH ST
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2426
Mailing Address - Country:US
Mailing Address - Phone:708-388-5500
Mailing Address - Fax:708-226-7170
Practice Address - Street 1:2320 HIGH ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2426
Practice Address - Country:US
Practice Address - Phone:708-388-5500
Practice Address - Fax:708-388-5672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCD5640OtherRAILROAD MEDICARE
IL01621031OtherBCBS PROVIDER ID
ILIL3596OtherLOCALITY15 MEDICARE
ILIL3596OtherLOCALITY15 MEDICARE
IL964290Medicare PIN
ILCD5640OtherRAILROAD MEDICARE
IL0562290001Medicare NSC
ILCD5640Medicare PIN