Provider Demographics
NPI:1932292521
Name:OBSTETRICS AND GYNECOLOGY CARE ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:OBSTETRICS AND GYNECOLOGY CARE ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-662-2273
Mailing Address - Street 1:1414 WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2817
Mailing Address - Country:US
Mailing Address - Phone:309-662-2273
Mailing Address - Fax:309-662-2014
Practice Address - Street 1:1414 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2817
Practice Address - Country:US
Practice Address - Phone:309-662-2273
Practice Address - Fax:309-662-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V000000X207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL193400000XOtherTAXONOMY
CK6294OtherRAILROAD MEDICARE
CK6294OtherRAILROAD MEDICARE
IL569390Medicare ID - Type Unspecified