1245296896 NPI number — ELLEN J GUSTAFSON MD

Table of content: ELLEN J GUSTAFSON MD (NPI 1245296896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245296896 NPI number — ELLEN J GUSTAFSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAFSON
Provider First Name:
ELLEN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245296896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1860 PAYSPHERE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-0018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-469-9200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2614 W JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-725-1355
Provider Business Practice Location Address Fax Number:
815-725-9857
Provider Enumeration Date:
04/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  036109139 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: K26698 . This is a "MEDICARE INDIV ID# FOR GROUP 208256" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: K26699 . This is a "MEDICARE INDIV ID# FOR GROUP 336140" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036109139 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K26697 . This is a "MEDICARE INDIV ID# FOR GROUP 205474" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00307129 . This is a "MEDICARE RR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com