Provider Demographics
NPI:1689872459
Name:CENTER FOR STUDY GU DISEASES
Entity Type:Organization
Organization Name:CENTER FOR STUDY GU DISEASES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-965-8505
Mailing Address - Street 1:4525 FOREST VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6406
Mailing Address - Country:US
Mailing Address - Phone:815-965-8505
Mailing Address - Fax:
Practice Address - Street 1:650 SPRING HILL RING RD STE 2000
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-1297
Practice Address - Country:US
Practice Address - Phone:847-836-8270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532219OtherBCBS ID