=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083972624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY SERVICES ENDOSCOPY SUITE, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2012
-----------------------------------------------------
Last Update Date | 05/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3825 HIGHLAND AVE STE 203
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-969-1167
-----------------------------------------------------
Fax | 630-969-1297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3825 HIGHLAND AVE STE 203
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-969-1167
-----------------------------------------------------
Fax | 630-969-1297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID PHILIP GERARD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-969-1167
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0800X
-----------------------------------------------------
Taxonomy Name | Endoscopy Clinic/Center
-----------------------------------------------------
License Number | 6827 782 5
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------