Provider Demographics
NPI:1831475466
Name:WESTERN DUPAGE OB/GYN
Entity Type:Organization
Organization Name:WESTERN DUPAGE OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:630-810-0777
Mailing Address - Street 1:609 REBECCA LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4859
Mailing Address - Country:US
Mailing Address - Phone:630-392-5025
Mailing Address - Fax:
Practice Address - Street 1:3800 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1557
Practice Address - Country:US
Practice Address - Phone:630-810-0777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN DUPAGE OB/GYN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty