Provider Demographics
NPI:1770721151
Name:DUPAGE MEDICAL GROUP, LTD.
Entity type:Organization
Organization Name:DUPAGE MEDICAL GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-469-9200
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 S HIGHLAND AVE
Practice Address - Street 2:L30
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4932
Practice Address - Country:US
Practice Address - Phone:630-873-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUPAGE MEDICAL GROUP, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-23
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042000124332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL785110OtherMEDICARE GROUP NUMBER
IL6180250012Medicare NSC