Provider Demographics
NPI:1992845358
Name:MID-CENTRAL ILL GASTRO
Entity Type:Organization
Organization Name:MID-CENTRAL ILL GASTRO
Other - Org Name:MID-CENTRAL ILL GAST LTD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-451-1123
Mailing Address - Street 1:2200 JACOBSSEN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5516
Mailing Address - Country:US
Mailing Address - Phone:309-451-1123
Mailing Address - Fax:309-451-1212
Practice Address - Street 1:2200 JACOBSSEN DR
Practice Address - Street 2:SUITE B
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-5516
Practice Address - Country:US
Practice Address - Phone:309-451-1123
Practice Address - Fax:309-451-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360818161Medicaid
IL05725403OtherBLUECROSS BLUESHIELD
IL0360788251Medicaid
IL0360818161Medicaid