Provider Demographics
NPI:1104815018
Name:GASTROENTEROLOGY ASSOCIATES SC
Entity type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KONICEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-871-4600
Mailing Address - Street 1:222 E DUNDEE RD
Mailing Address - Street 2:GASTROENTEROLOGY & ASSOCIATES SC
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3009
Mailing Address - Country:US
Mailing Address - Phone:847-520-0235
Mailing Address - Fax:847-520-0390
Practice Address - Street 1:3004 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3012
Practice Address - Country:US
Practice Address - Phone:773-871-4600
Practice Address - Fax:773-871-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
603380Medicare ID - Type Unspecified
ILCF3440Medicare Oscar/Certification