Healthcare Provider Details

I. General information

NPI: 1275761488
Provider Name (Legal Business Name): NICHOLE SUZANNE LUPEI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 N KEDZIE BLVD
CHICAGO IL
60647-2603
US

IV. Provider business mailing address

701 LEE ST SUITE 300
DES PLAINES IL
60016-4539
US

V. Phone/Fax

Practice location:
  • Phone: 773-292-2700
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-056508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: