Healthcare Provider Details

I. General information

NPI: 1104815018
Provider Name (Legal Business Name): GASTROENTEROLOGY ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3004 N ASHLAND AVE
CHICAGO IL
60657-3012
US

IV. Provider business mailing address

222 E DUNDEE RD GASTROENTEROLOGY & ASSOCIATES SC
WHEELING IL
60090-3009
US

V. Phone/Fax

Practice location:
  • Phone: 773-871-4600
  • Fax: 773-871-2900
Mailing address:
  • Phone: 847-520-0235
  • Fax: 847-520-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: FRANK J KONICEK
Title or Position: PRESIDENT
Credential: MD
Phone: 773-871-4600