Provider Demographics
NPI:1336287168
Name:WINCHESTER ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:WINCHESTER ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:STICKAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:847-247-0187
Mailing Address - Street 1:1880 W WINCHESTER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5341
Mailing Address - Country:US
Mailing Address - Phone:847-247-0187
Mailing Address - Fax:847-247-0487
Practice Address - Street 1:1880 W WINCHESTER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5341
Practice Address - Country:US
Practice Address - Phone:847-247-0187
Practice Address - Fax:847-247-0487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty