Basic Information
| Provider Information | |||||||||
| NPI: | 1801833983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DU PAGE MEDICAL GROUP LTD | ||||||||
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| OtherOrganizationName: | DUPAGE 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 W 31ST ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605155509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | TEMPLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6304567211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 054018228 | IL | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 054018228 | IL | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 335E00000X | 042000124 | IL | N | Suppliers | Prosthetic/Orthotic Supplier | 333600000X | 054018228 | IL | N | Suppliers | Pharmacy | 332B00000X | 042000124 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332H00000X | 042000124 | IL | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 261QM1300X | 042000124 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 205994 | 01 | IL | MEDICARE GROUP NUMBER | OTHER | 200502 | 01 | IL | MEDICARE GROUP NUMBER | OTHER | 568660 | 01 | IL | MEDICARE GROUP NUMBER | OTHER | 584330 | 01 | IL | MEDICARE GROUP NUMBER | OTHER | 785110 | 01 | IL | PTAN | OTHER | 569810 | 01 | IL | MEDICARE GROUP NUMBER | OTHER |