Healthcare Provider Details

I. General information

NPI: 1568485043
Provider Name (Legal Business Name): ANTON JOHN DUBRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W SCHWARTZ ST
SALEM IL
62881-1552
US

IV. Provider business mailing address

420 W SCHWARTZ ST
SALEM IL
62881-1552
US

V. Phone/Fax

Practice location:
  • Phone: 618-740-4667
  • Fax: 618-740-1482
Mailing address:
  • Phone: 618-740-4667
  • Fax: 618-740-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036-061031
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036061031
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number036-061031
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036061031
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: