Basic Information
| Provider Information | |||||||||
| NPI: | 1801906094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEKULIC | ||||||||
| FirstName: | DUSICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 PRAIRIE ROSE DR | ||||||||
| Address2: | |||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610737792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 PRAIRIE ROSE DR | ||||||||
| Address2: | |||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610737792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036087260 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036087260 | 05 | IL | MEDICAID |