Healthcare Provider Details

I. General information

NPI: 1316456965
Provider Name (Legal Business Name): ANTON DUBRICK MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 07/21/2022
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 TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036061031
License Number StateIL

VIII. Authorized Official

Name: ANTON DUBRICK
Title or Position: PRESIDENT
Credential: MD
Phone: 618-740-4667