Provider Demographics
NPI:1699874255
Name:CHILDRENS GASTROENTEROLOGY SPECIALISTS SC
Entity type:Organization
Organization Name:CHILDRENS GASTROENTEROLOGY SPECIALISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-724-7825
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-789-2550
Mailing Address - Fax:
Practice Address - Street 1:2551 COMPASS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8045
Practice Address - Country:US
Practice Address - Phone:847-724-7825
Practice Address - Fax:847-724-7845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634323OtherBCBS PROVIDER ID
IL216027Medicare PIN
IL1634323OtherBCBS PROVIDER ID