Provider Demographics
NPI:1760550495
Name:GASTROENTEROLOGY AND LIVER DISEASE ASSOCIATES LLC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY AND LIVER DISEASE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:S
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-318-9595
Mailing Address - Street 1:7900 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE 19
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3159
Mailing Address - Country:US
Mailing Address - Phone:847-318-9595
Mailing Address - Fax:847-318-9599
Practice Address - Street 1:7900 N MILWAUKEE AVE
Practice Address - Street 2:SUITE 19
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3159
Practice Address - Country:US
Practice Address - Phone:847-318-9595
Practice Address - Fax:847-318-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCJ6281OtherRAIL ROAD MEDICARE
IL549220Medicare PIN