Provider Demographics
NPI:1881846137
Name:CENTER FOR DIGESTIVE HEALTH
Entity Type:Organization
Organization Name:CENTER FOR DIGESTIVE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-936-1700
Mailing Address - Street 1:1615 N CONVENT ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1092
Mailing Address - Country:US
Mailing Address - Phone:815-936-1700
Mailing Address - Fax:
Practice Address - Street 1:1615 N CONVENT ST STE 2
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1092
Practice Address - Country:US
Practice Address - Phone:815-936-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002876261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========01Medicaid