Provider Demographics
NPI:1336323484
Name:PEDIATRIC AND ADOLESCENT GASTROENTEROLOGY GROUP INC
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT GASTROENTEROLOGY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-499-7510
Mailing Address - Street 1:47 W DIVISION ST UNIT 142
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2220
Mailing Address - Country:US
Mailing Address - Phone:708-499-7510
Mailing Address - Fax:708-345-0332
Practice Address - Street 1:1225 W LAKE ST
Practice Address - Street 2:SUITE 409
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60610
Practice Address - Country:US
Practice Address - Phone:708-499-7510
Practice Address - Fax:708-345-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360625372080P0206X
IN10001559022080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D16746Medicare UPIN