=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134153133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCHITA G GAVINO MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 11/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 SUMMIT ST SUITE 254
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-4339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-695-8721
-----------------------------------------------------
Fax | 847-695-8755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 860 SUMMIT ST SUITE 254
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-4339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-695-8721
-----------------------------------------------------
Fax | 847-695-8755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CONCHITA G GAVINO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-695-8721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 042005671
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------