MEDICARE: DUPAGE MEDICAL GROUP, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	437	OTHER	IL	BCBS HMO SITE

General Provider Information

NPI Number	:	1851425714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUPAGE MEDICAL GROUP, LTD

Provider Business Mailing Address
First Line	:	PO BOX 713260
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-1260
Country	:	US
Telephone Number	:	630-469-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 31ST ST
Second Line	:	STE. 300
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-5509
Country	:	US
Telephone Number	:	630-469-9200
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN OF THE BOARD
Name	:	PAUL MERRICK
Credential	:	MD
Telephone Number	:	630-790-1221

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	10/13/2023

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