Basic Information
| Provider Information | |||||||||
| NPI: | 1992875454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELGIN GASTROENTEROLOGY ENDOSCOPY CENTER LLC | ||||||||
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| OtherOrganizationName: | THE ENDO CENTER OF ELGIN GASTROENTEROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 YORK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JAMISON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189291098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155899024 | ||||||||
| FaxNumber: | 8337056301 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 FLETCHER DR FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478881300 | ||||||||
| FaxNumber: | 8478881341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOHLFELD | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PAYER CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 2155899024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1710262 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 50438 | 01 | IL | BLUE SHIELD | OTHER |