Healthcare Provider Details

I. General information

NPI: 1679543151
Provider Name (Legal Business Name): JOSEPHINE DLUGOPOLSKI-GACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S FIRST AVE (9608 ROBERTS RD, HICKORY HILLS, ILLINOIS 60457)
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S FIRST AVE (9608 ROBERTS RD, HICKORY HILLS, ILLINOIS 60457)
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-233-5333
  • Fax: 708-233-5348
Mailing address:
  • Phone: 708-233-5333
  • Fax: 708-233-5348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36112666
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36112666
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: