Healthcare Provider Details

I. General information

NPI: 1174670723
Provider Name (Legal Business Name): GASTROINTESTINAL INSTITUTE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 JACOBSSEN DR STE A
NORMAL IL
61761-5516
US

IV. Provider business mailing address

2200 JACOBSSEN DR SUITE A
NORMAL IL
61761-5516
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-1121
  • Fax: 309-451-1212
Mailing address:
  • Phone: 309-451-1121
  • Fax: 309-451-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7003056
License Number StateIL

VIII. Authorized Official

Name: MR. PHIL ARTHUR MCGOWAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 309-451-1123