Provider Demographics
NPI:1043624752
Name:DIAMOND GASTROENTEROLOGY SC
Entity Type:Organization
Organization Name:DIAMOND GASTROENTEROLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILYSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-613-4417
Mailing Address - Street 1:1010 LAKE ST STE 424
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1185
Mailing Address - Country:US
Mailing Address - Phone:708-613-4417
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKE ST STE 424
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1185
Practice Address - Country:US
Practice Address - Phone:708-613-4417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36120184207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty