Basic Information
| Provider Information | |||||||||
| NPI: | 1639299977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYBIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5140 N CALIFORNIA AVE | ||||||||
| Address2: | SUITE 780 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732735332 | ||||||||
| Practice Location | |||||||||
| Address1: | 5140 N CALIFORNIA AVE | ||||||||
| Address2: | SUITE 780 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732735332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036114053 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036114053 1 | 05 | IL | MEDICAID | 036114053 2 | 05 | IL | MEDICAID | 1630046 | 01 | IL | BCBS OF IL GROUP NUMBER | OTHER | 036114053 | 05 | IL | MEDICAID | 1629966 | 01 | IL | BS OF IL GROUP # NIESS | OTHER |