Individual
ELLEN J GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2614 W JEFFERSON ST, JOLIET, IL 60435
(815) 725-1355
(815) 725-9857
Mailing address
1860 PAYSPHERE CIR, CHICAGO, IL 60674-0018
(630) 469-9200
Taxonomy
Speciality
Code
Description
License number
State
207RH0003X
Hematology & Oncology Physician
Primary
036109139
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036109139
—
IL
01
—
K26697
MEDICARE INDIV ID# FOR GROUP 205474
IL
01
—
K26698
MEDICARE INDIV ID# FOR GROUP 208256
IL
01
—
K26699
MEDICARE INDIV ID# FOR GROUP 336140
IL
01
—
P00307129
MEDICARE RR
IL
Enumeration date
04/24/2006
Last updated
04/25/2025
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