Healthcare Provider Details

I. General information

NPI: 1902426026
Provider Name (Legal Business Name): DYLAN J DOUGLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N WESTMORELAND RD # LEVEL1
LAKE FOREST IL
60045-1658
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-1800
  • Fax: 847-535-7151
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.075528
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036163698
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036163698
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: