Healthcare Provider Details

I. General information

NPI: 1619965266
Provider Name (Legal Business Name): ASSOCIATED GASTROENTEROLOGY CONSULTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 PARK AVE E SUITE 207
PRINCETON IL
61356-3901
US

IV. Provider business mailing address

530 PARK AVE E SUITE 207
PRINCETON IL
61356-3901
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-8666
  • Fax: 815-872-0487
Mailing address:
  • Phone: 815-875-8666
  • Fax: 815-872-0487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number209005803
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036085799
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036062499
License Number StateIL

VIII. Authorized Official

Name: MRS. GINA DORAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-875-7666