MEDICARE: WESTERN DUPAGE OB/GYN

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	363AM0700X	Medical Physician Assistant	085004210	IL

General Provider Information

NPI Number	:	1831475466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN DUPAGE OB/GYN

Provider Business Mailing Address
First Line	:	609 REBECCA LN
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4859
Country	:	US
Telephone Number	:	630-392-5025
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 HIGHLAND AVE
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1557
Country	:	US
Telephone Number	:	630-810-0777
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN ASSISTANT
Name	:	DANIELLE MARIE EVERETT
Credential	:	PA-C
Telephone Number	:	630-810-0777

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	10/27/2011

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Directions to “WESTERN DUPAGE OB/GYN ” Practice Location

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