Provider Demographics
NPI:1699946566
Name:INTERNAL MEDICINE ASSOCIATES OF DUPAGE COUNTY
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF DUPAGE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-980-5480
Mailing Address - Street 1:2198 GLADSTONE CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1514
Mailing Address - Country:US
Mailing Address - Phone:630-980-5480
Mailing Address - Fax:630-980-5485
Practice Address - Street 1:2198 GLADSTONE CT
Practice Address - Street 2:SUITE A
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-1514
Practice Address - Country:US
Practice Address - Phone:630-980-5480
Practice Address - Fax:630-980-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00271772OtherRAILROAD MEDICARE
IL2232761OtherBC/BS
IL212200Medicare PIN