MEDICARE: ASSOCIATED GASTROENTEROLOGY CONSULTANTS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	209005803	IL
2	207RG0100X	Gastroenterology Physician	036085799	IL
3	207RG0100X	Gastroenterology Physician	036062499	IL

General Provider Information

NPI Number	:	1619965266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASSOCIATED GASTROENTEROLOGY CONSULTANTS, INC.

Provider Business Mailing Address
First Line	:	530 PARK AVE E
Second Line	:	SUITE 207
City	:	PRINCETON
State	:	IL
Zip	:	61356-3901
Country	:	US
Telephone Number	:	815-875-8666
Fax Number	:	815-872-0487

Provider Business Practice Location Address
First Line	:	530 PARK AVE E
Second Line	:	SUITE 207
City	:	PRINCETON
State	:	IL
Zip	:	61356-3901
Country	:	US
Telephone Number	:	815-875-8666
Fax Number	:	815-872-0487

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. GINA DORAN
Credential	:
Telephone Number	:	815-875-7666

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	08/26/2015

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