MEDICARE: DUPAGE META-VASCULAR MEDICINE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	036047587	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2232209	OTHER	IL	BLUE SHIELD NUMBER
2	1366581811	OTHER	IL	GROUP NPI
3	P00843099	OTHER	IL	RAIL ROAD

General Provider Information

NPI Number	:	1366581811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUPAGE META-VASCULAR MEDICINE PC

Provider Business Mailing Address
First Line	:	245 S GARY AVE
Second Line	:	SUITE 202
City	:	BLOOMINGDALE
State	:	IL
Zip	:	60108-2228
Country	:	US
Telephone Number	:	630-893-2190
Fax Number	:	630-307-8716

Provider Business Practice Location Address
First Line	:	245 S GARY AVE
Second Line	:	SUITE 202
City	:	BLOOMINGDALE
State	:	IL
Zip	:	60108-2228
Country	:	US
Telephone Number	:	630-893-2190
Fax Number	:	630-307-8716

Authorized Official
Title or Position	:	RN/PRACTICE MANAGER
Name	:	MS. BARBARA MARY KOSIEK
Credential	:
Telephone Number	:	630-893-2190

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	02/04/2011

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