Provider Demographics
NPI:1306056734
Name:PAWEL S. DUDEK, M.D., S.C.
Entity type:Organization
Organization Name:PAWEL S. DUDEK, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED PSYCHIATRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAWEL
Authorized Official - Middle Name:STANISLAW
Authorized Official - Last Name:DUDEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-909-6269
Mailing Address - Street 1:4840 N MARINE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7860
Mailing Address - Country:US
Mailing Address - Phone:773-654-1645
Mailing Address - Fax:773-681-0289
Practice Address - Street 1:4250 N MARINE DR
Practice Address - Street 2:SUITE 236
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1744
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:773-404-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360963272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096327Medicaid
IL401806OtherHARMONY
IL01635497OtherBLUE CROSS BLUE SHIELD
IL2017926OtherCIGNA
IL404206OtherVALUE OPTIONS
IL180759OtherCOMPSYCH
IL415428OtherMHN
IL=========OtherTAX ID
ILG59398Medicare UPIN
IL212390Medicare ID - Type Unspecified