Provider Demographics
NPI:1316456965
Name:ANTON DUBRICK MD SC
Entity type:Organization
Organization Name:ANTON DUBRICK MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-740-4667
Mailing Address - Street 1:420 W SCHWARTZ ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1552
Mailing Address - Country:US
Mailing Address - Phone:618-740-4667
Mailing Address - Fax:618-740-1482
Practice Address - Street 1:420 W SCHWARTZ ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1552
Practice Address - Country:US
Practice Address - Phone:618-740-4667
Practice Address - Fax:618-740-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty