Provider Demographics
NPI:1275575706
Name:ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Entity Type:Organization
Organization Name:ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Other - Org Name:GASTROENTEROLOGY, LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-4980
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-0365
Mailing Address - Country:US
Mailing Address - Phone:309-672-4980
Mailing Address - Fax:309-671-2944
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 500A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:309-671-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042006270207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215152OtherBLUE CROSS
ILCE0700OtherRAILROAD MEDICARE
ILCE0700OtherRAILROAD MEDICARE