Healthcare Provider Details

I. General information

NPI: 1740354679
Provider Name (Legal Business Name): GARY S. CHURCHILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 OLD NORTHWEST HWY THE CENTER FOR FACIAL PLASTIC SURGERY
BARRINGTON IL
60010
US

IV. Provider business mailing address

515 OLD NORTHWEST HWY THE CENTER FOR FACIAL PLASTIC SURGERY
BARRINGTON IL
60010
US

V. Phone/Fax

Practice location:
  • Phone: 847-304-1000
  • Fax: 847-304-1182
Mailing address:
  • Phone: 847-304-1000
  • Fax: 847-304-1182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number036-079243
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: