Provider Demographics
NPI:1245296896
Name:GUSTAFSON, ELLEN J (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:J
Last Name:GUSTAFSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:2614 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-725-1355
Practice Address - Fax:815-725-9857
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109139207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26698OtherMEDICARE INDIV ID# FOR GROUP 208256
ILK26699OtherMEDICARE INDIV ID# FOR GROUP 336140
IL036109139Medicaid
ILK26697OtherMEDICARE INDIV ID# FOR GROUP 205474
ILP00307129OtherMEDICARE RR
IL336140Medicare PIN
IL208256Medicare PIN
IL205474Medicare PIN
ILK26698OtherMEDICARE INDIV ID# FOR GROUP 208256