Healthcare Provider Details

I. General information

NPI: 1316206733
Provider Name (Legal Business Name): JOSEPH Z. PUDLO, M.D. S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6145 N. MILWAUKEE AVE
CHICAGO IL
60646-3804
US

IV. Provider business mailing address

6145 N. MILWAUKEE AVE
CHICAGO IL
60646-3804
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-2442
  • Fax: 773-631-6530
Mailing address:
  • Phone: 773-631-2442
  • Fax: 773-631-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-072100
License Number StateIL

VIII. Authorized Official

Name: JOSEPH ZBIGNIEW PUDLO
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 773-631-2442