Healthcare Provider Details

I. General information

NPI: 1841552999
Provider Name (Legal Business Name): ADVANCED LIVER AND GASTROINTESTINAL DISEASE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 GROVE AVE
BERWYN IL
60402-3474
US

IV. Provider business mailing address

401 E ONTARIO ST SUITE#4005
CHICAGO IL
60611-3051
US

V. Phone/Fax

Practice location:
  • Phone: 414-236-7224
  • Fax: 708-290-1014
Mailing address:
  • Phone: 312-573-1633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberIL036096121
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License NumberIL036096121
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID H VANTHIEL
Title or Position: PRESIDENT
Credential: MD
Phone: 312-573-1633