Basic Information
| Provider Information | |||||||||
| NPI: | 1275878134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DU PAGE MEDICAL GROUP LTD | ||||||||
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| OtherOrganizationName: | DU PAGE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1948 THREE FARMS AVE | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605401105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305478000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | TEMPLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6304699200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DU PAGE MEDICAL GROUP LTD | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | 042000124 | IL | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | 042000124 | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 205994 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 785110 | 01 | IL | MEDICARE GROUP PTAN | OTHER |