Healthcare Provider Details

I. General information

NPI: 1548414063
Provider Name (Legal Business Name): CHICAGO GASTRO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 W GEORGE ST STE 101
CHICAGO IL
60657-5893
US

IV. Provider business mailing address

PO BOX 14763
CHICAGO IL
60614-0763
US

V. Phone/Fax

Practice location:
  • Phone: 773-537-0020
  • Fax:
Mailing address:
  • Phone: 773-537-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANDREW ALBERT
Title or Position: DIRECTOR
Credential: M.D.
Phone: 773-537-0020