Provider Demographics
NPI:1366792426
Name:CHICAGO GASTROENTEROLOGY, LLC
Entity type:Organization
Organization Name:CHICAGO GASTROENTEROLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:FRANCISCO
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-708-7496
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 133
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:773-342-6800
Mailing Address - Fax:773-342-6332
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 133
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-342-6800
Practice Address - Fax:773-342-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL248000667207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL692861OtherMEDICARE
IL1205801313OtherNPI
IL036122662Medicaid
IL036063975Medicaid
IL1467503672OtherNPI
ILI17297OtherMEDICARE