Provider Demographics
NPI:1700018710
Name:DOWNERS GROVE GERIATRICS LLC
Entity Type:Organization
Organization Name:DOWNERS GROVE GERIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYORGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-241-3779
Mailing Address - Street 1:4411 ROSLYN RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5804
Mailing Address - Country:US
Mailing Address - Phone:630-241-3779
Mailing Address - Fax:630-241-9309
Practice Address - Street 1:3800 HIGHLAND AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1557
Practice Address - Country:US
Practice Address - Phone:630-241-3779
Practice Address - Fax:630-241-9309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106287207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty