1275575706 NPI number — ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC

Table of content: (NPI 1275575706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275575706 NPI number — ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GASTROENTEROLOGY, LTD
Provider Other Organization Name Type Code:
4
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:
1275575706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 365
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61550-0365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-672-4980
Provider Business Mailing Address Fax Number:
309-671-2944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 500A
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61606-1907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-672-4980
Provider Business Practice Location Address Fax Number:
309-671-2944
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHADLEY
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
309-672-4980

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  042006270 , 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: 07215152 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE0700 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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