Healthcare Provider Details

I. General information

NPI: 1871793646
Provider Name (Legal Business Name): ELITE GYNECOLOGY S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 W US ROUTE 6
MORRIS IL
60450-8858
US

IV. Provider business mailing address

936 W US ROUTE 6
MORRIS IL
60450-8858
US

V. Phone/Fax

Practice location:
  • Phone: 815-942-0525
  • Fax: 815-942-3501
Mailing address:
  • Phone: 815-942-0525
  • Fax: 815-942-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036082983
License Number StateIL

VIII. Authorized Official

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