Provider Demographics
NPI:1760416762
Name:FOX VALLEY NEUROLOGY PC
Entity Type:Organization
Organization Name:FOX VALLEY NEUROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAVINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-695-8721
Mailing Address - Street 1:860 SUMMIT ST
Mailing Address - Street 2:STE 254
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4339
Mailing Address - Country:US
Mailing Address - Phone:847-695-8721
Mailing Address - Fax:847-695-8755
Practice Address - Street 1:860 SUMMIT ST
Practice Address - Street 2:STE 254
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4339
Practice Address - Country:US
Practice Address - Phone:847-695-8721
Practice Address - Fax:847-695-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600007352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1615763OtherBLUE CROSS BLUE SHIELD
210722Medicare ID - Type Unspecified