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General NPI Number Information
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NPI Number | 1629334305
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Entity Type | Organization
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Legal Business Name | RONALD TUPIK D O LTD
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Dates
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Enumeration Date | 04/06/2012
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Last Update Date | 04/06/2012
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Provider Practice Location Address
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Address Line | 500 E MAPLE SUITE 203
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City | NEW LENOX
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State | IL
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Zip | 60451-2908
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Country | US
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Telephone | 815-485-9160
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Fax | 815-485-9176
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Provider Business Mailing Address
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Address Line | 500 E MAPLE SUITE 203
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City | NEW LENOX
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State | IL
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Zip | 60451-2908
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Country | US
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Telephone | 815-485-9160
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Fax | 815-485-9176
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Authorized Official
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Title or Position | OWNER
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Name | DR. RONALD E TUPIK
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Credential | DO
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Telephone | 815-485-9160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036057035
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License Number State | IL
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