Provider Demographics
NPI:1962403212
Name:GASTROENTEROLOGY CONSULTANTS OF THE NORTH SHORE
Entity type:Organization
Organization Name:GASTROENTEROLOGY CONSULTANTS OF THE NORTH SHORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YOLANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-256-8661
Mailing Address - Street 1:505 PARK DR
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1082
Mailing Address - Country:US
Mailing Address - Phone:847-256-8661
Mailing Address - Fax:847-256-1598
Practice Address - Street 1:505 PARK DR
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1082
Practice Address - Country:US
Practice Address - Phone:847-256-8661
Practice Address - Fax:847-256-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL389680Medicare PIN