Basic Information
| Provider Information | |||||||||
| NPI: | 1881220150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUPLICKI | ||||||||
| FirstName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 N DEARBORN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606544618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126942273 | ||||||||
| FaxNumber: | 3126942129 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 N DEARBORN ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606544618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126942273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2020 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085007895 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.