Provider Demographics
NPI:1336260488
Name:GERIATRIC CARE SPECIALISTS,LTD
Entity Type:Organization
Organization Name:GERIATRIC CARE SPECIALISTS,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-440-4281
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-0900
Mailing Address - Country:US
Mailing Address - Phone:630-440-4281
Mailing Address - Fax:
Practice Address - Street 1:512 HILLGROVE AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1442
Practice Address - Country:US
Practice Address - Phone:630-440-4281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075925207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214973Medicare PIN