Basic Information
Provider Information | |||||||||
NPI: | 1891933255 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DUPAGE MEDICAL GROUP, LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1860 PAYSPHERE CIR | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606740018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6304699200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1327 BUTTERFIELD RD | ||||||||
Address2: | 618 | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605151078 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303228300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2009 | ||||||||
LastUpdateDate: | 03/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TEMPLER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6304567211 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DUPAGE MEDICAL GROUP, LTD. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 042-000124 | IL | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 785110 | 01 | IL | MEDICARE GROUP NUMBER | OTHER |