Basic Information
| Provider Information | |||||||||
| NPI: | 1609890581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRUECK | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W 79TH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604592190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738844500 | ||||||||
| FaxNumber: | 7738844580 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 YALE CT | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600265916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472724682 | ||||||||
| FaxNumber: | 8472724691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036045746 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020052114 | 01 | RAILROAD MEDICARE | OTHER | 01632718 | 01 | IL | BLUE SHIELD | OTHER | 036045746 | 05 | IL | MEDICAID |