Healthcare Provider Details

I. General information

NPI: 1316292436
Provider Name (Legal Business Name): DAVID MICHAEL PODREBARAC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2012
Last Update Date: 07/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 SOUTHWEST HWY
HOMETOWN IL
60456-1135
US

IV. Provider business mailing address

16509 CHERRY HILL AVE
TINLEY PARK IL
60487-1140
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-5700
  • Fax:
Mailing address:
  • Phone: 708-699-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125061608
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: