MEDICARE: DR. PHILIP S DUDAK DC, FNP-C

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	111N00000X	Chiropractor	005778	MO
2	363L00000X	Nurse Practitioner	2013003629	MO
3	111N00000X	Chiropractor	038006559	IL
4	363L00000X	Nurse Practitioner	209010226	IL
5	363LF0000X	Family Nurse Practitioner	2013003629	MO
6	363LF0000X	Family Nurse Practitioner	209010226	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	118828	OTHER	IL	BCBS
2	4400267	OTHER		UHC

General Provider Information

NPI Number	:	1720067051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP S DUDAK DC, FNP-C

Provider Business Mailing Address
First Line	:	11125 DUNN RD STE 100
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6132
Country	:	US
Telephone Number	:	314-653-5228
Fax Number	:

Provider Business Practice Location Address
First Line	:	11133 DUNN RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6163
Country	:	US
Telephone Number	:	314-653-5228
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	07/29/2021

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Directions to “ DR. PHILIP S DUDAK DC, FNP-C” Practice Location

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