Provider Demographics
NPI: | 1801833983 |
---|---|
Name: | DUPAGE MEDICAL GROUP LTD |
Entity Type: | Organization |
Organization Name: | DUPAGE MEDICAL GROUP LTD |
Other - Org Name: | DUPAGE MEDICAL GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT, BOARD OF DIRECTORS |
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: | PO BOX 713260 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60677-1260 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 630-469-9200 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1100 W 31ST ST |
Practice Address - Street 2: | STE 300 |
Practice Address - City: | DOWNERS GROVE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60515-5509 |
Practice Address - Country: | US |
Practice Address - Phone: | 630-469-9200 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-31 |
Last Update Date: | 2023-08-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 042000124 | 261QM1300X, 332B00000X, 332H00000X, 335E00000X |
IL | 054018228 | 333600000X, 3336C0002X, 3336C0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | |
No | 332H00000X | Suppliers | Eyewear Supplier | |
No | 333600000X | Suppliers | Pharmacy | |
No | 3336C0002X | Suppliers | Pharmacy | Clinic Pharmacy |
No | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
No | 335E00000X | Suppliers | Prosthetic/Orthotic Supplier |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 568660 | Other | MEDICARE GROUP NUMBER |
IL | 785110 | Other | PTAN |
IL | 200502 | Other | MEDICARE GROUP NUMBER |
IL | 584330 | Other | MEDICARE GROUP NUMBER |
IL | 205994 | Other | MEDICARE GROUP NUMBER |
IL | 569810 | Other | MEDICARE GROUP NUMBER |
IL | 584330 | Other | MEDICARE GROUP NUMBER |
IL | 6180250007 | Medicare NSC | |
IL | 6180250008 | Medicare NSC | |
IL | 6180250014 | Medicare NSC | |
IL | 6180250042 | Medicare NSC | |
IL | 6180250011 | Medicare NSC | |
IL | 6180250012 | Medicare NSC | |
IL | 6180250025 | Medicare NSC | |
IL | 6180250027 | Medicare NSC | |
IL | 6180250003 | Medicare NSC | |
IL | 6180250013 | Medicare NSC | |
IL | 6180250024 | Medicare NSC | |
IL | 6180250016 | Medicare NSC | |
IL | 6180250020 | Medicare NSC | |
IL | 6180250026 | Medicare NSC | |
IL | 569810 | Other | MEDICARE GROUP NUMBER |
IL | 785110 | Other | PTAN |
IL | 6180250010 | Medicare NSC | |
IL | 6180250017 | Medicare NSC | |
IL | 6180250005 | Medicare NSC | |
IL | 6180250002 | Medicare NSC | |
IL | 205994 | Other | MEDICARE GROUP NUMBER |
IL | 6180250009 | Medicare NSC | |
IL | 6180250015 | Medicare NSC | |
IL | 6180250019 | Medicare NSC | |
IL | 6180250021 | Medicare NSC | |
IL | 6180250023 | Medicare NSC | |
IL | 6180250006 | Medicare NSC | |
IL | 6180250001 | Medicare NSC |