Healthcare Provider Details

I. General information

NPI: 1881958106
Provider Name (Legal Business Name): ADVANCED LIVER AND GASTROINTESTINAL DISEASE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 SOUTH MAPLE AVE
OAK PARK IL
60304-1091
US

IV. Provider business mailing address

401 E ONTARIO STR. SUITE #4005
CHICAGO IL
60611-7179
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036096121
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number036096121
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number036096121
License Number StateIL

VIII. Authorized Official

Name: DR. MAGDALENA GEORGE
Title or Position: MANAGER/OWNER
Credential: MS, PHD.
Phone: 312-573-1633