Provider Demographics
NPI:1366581811
Name:DUPAGE META-VASCULAR MEDICINE PC
Entity type:Organization
Organization Name:DUPAGE META-VASCULAR MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:KOSIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-893-2190
Mailing Address - Street 1:245 S GARY AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2228
Mailing Address - Country:US
Mailing Address - Phone:630-893-2190
Mailing Address - Fax:630-307-8716
Practice Address - Street 1:245 S GARY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2228
Practice Address - Country:US
Practice Address - Phone:630-893-2190
Practice Address - Fax:630-307-8716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047587207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232209OtherBLUE SHIELD NUMBER
IL1366581811OtherGROUP NPI
ILP00843099OtherRAIL ROAD
ILP00843099OtherRAIL ROAD
ILDQ4596Medicare PIN