Basic Information
| Provider Information | |||||||||
| NPI: | 1316277817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS GASTROENTEROLOGY GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GI ALLIANCE OF ILLINOIS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 FLETCHER DRIVE | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478881300 | ||||||||
| FaxNumber: | 8478881341 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 FLETCHER DRIVE | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478881300 | ||||||||
| FaxNumber: | 8478881341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERNSEN | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8474391005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.