Basic Information
| Provider Information | |||||||||
| NPI: | 1629043344 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC ENDOSCOPY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 PARK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605632688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307180200 | ||||||||
| FaxNumber: | 6307180900 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 N SAINT CLAIR ST | ||||||||
| Address2: | SUITE 1525A | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129433723 | ||||||||
| FaxNumber: | 3122661411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | PARSONS | ||||||||
| AuthorizedOfficialFirstName: | WILLIS | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6307180200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01627695 | 01 | IL | BLUE CROSS / BLUE SHIELD | OTHER |