Provider Demographics
NPI:1740354679
Name:CHURCHILL, GARY S (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 OLD NORTHWEST HWY
Mailing Address - Street 2:THE CENTER FOR FACIAL PLASTIC SURGERY
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010
Mailing Address - Country:US
Mailing Address - Phone:847-304-1000
Mailing Address - Fax:847-304-1182
Practice Address - Street 1:515 OLD NORTHWEST HWY
Practice Address - Street 2:THE CENTER FOR FACIAL PLASTIC SURGERY
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010
Practice Address - Country:US
Practice Address - Phone:847-304-1000
Practice Address - Fax:847-304-1182
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-079243261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL63393Medicare UPIN
IL421450Medicare ID - Type Unspecified