MEDICARE: ELITE GYNECOLOGY S.C.

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	207V00000X	Obstetrics & Gynecology Physician	036082983	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3229984	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1871793646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE GYNECOLOGY S.C.

Provider Business Mailing Address
First Line	:	936 W US ROUTE 6
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-8858
Country	:	US
Telephone Number	:	815-942-0525
Fax Number	:	815-942-3501

Provider Business Practice Location Address
First Line	:	936 W US ROUTE 6
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-8858
Country	:	US
Telephone Number	:	815-942-0525
Fax Number	:	815-942-3501

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. PETER P VIENNE JR.
Credential	:	D.O.
Telephone Number	:	815-942-0525

Provider Enumeration Date	:	07/20/2007
Last Update Date	:	07/01/2015

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Directions to “ELITE GYNECOLOGY S.C. ” Practice Location

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