Provider Demographics
NPI:1477673275
Name:MIDLICK, DAVID GEORGE (CCT,BA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:GEORGE
Last Name:MIDLICK
Suffix:
Gender:M
Credentials:CCT,BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6686 DOUBLE EAGLE DR
Mailing Address - Street 2:UNIT 103
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-5428
Mailing Address - Country:US
Mailing Address - Phone:630-663-9811
Mailing Address - Fax:630-663-9018
Practice Address - Street 1:6686 DOUBLE EAGLE DR
Practice Address - Street 2:UNIT 103
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-5428
Practice Address - Country:US
Practice Address - Phone:630-663-9811
Practice Address - Fax:630-663-9018
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C1101XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiovascular-Interventional Technology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364429849001Medicaid
ILBLUE CROSSOther02230032
IL201811Medicare ID - Type Unspecified