Basic Information
Provider Information | |||||||||
NPI: | 1417159377 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TUBIC | ||||||||
FirstName: | GORAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 420 REMINGTON BLVD | ||||||||
Address2: | SUITE 240 | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604404925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303124505 | ||||||||
FaxNumber: | 6303126868 | ||||||||
Practice Location | |||||||||
Address1: | 420 S. SCHMIDT ROAD | ||||||||
Address2: | STE. 110 | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604401737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303124562 | ||||||||
FaxNumber: | 6303126651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2007 | ||||||||
LastUpdateDate: | 08/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036115600 | IL | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 036115600 | IL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.