Basic Information
Provider Information | |||||||||
NPI: | 1679603302 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUANDALINI | ||||||||
FirstName: | STEFANO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D, | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | UNIVERSITY OF CHICAGO, SECTION OF PEDS GASTRO | ||||||||
Address2: | 5839 SOUTH MARYLAND AVENUE, MC 4065 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606371470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7737026418 | ||||||||
FaxNumber: | 7737020666 | ||||||||
Practice Location | |||||||||
Address1: | UNIVERSITY OF CHICAGO, SECTION OF PEDS GASTRO | ||||||||
Address2: | 5839 SOUTH MARYLAND AVENUE, MC 4065 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606371470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7737026418 | ||||||||
FaxNumber: | 7737020666 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X |   | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 2000092610 | 05 | IN |   | MEDICAID |