Provider Demographics
NPI:1205886959
Name:DURICK, NATHAN A (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:DURICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 VALLEY VIEW DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6150
Mailing Address - Country:US
Mailing Address - Phone:309-762-1072
Mailing Address - Fax:309-762-1094
Practice Address - Street 1:615 VALLEY VIEW DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6150
Practice Address - Country:US
Practice Address - Phone:309-762-1072
Practice Address - Fax:309-762-1094
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48339-202085R0202X
IA375202085R0202X
IL0361146872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00615569Medicare PIN
ILR01096Medicare PIN
IL209395002Medicare PIN
IAI08480001Medicare PIN
IAP00615567Medicare PIN
IL036114687Medicaid