Organization
ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Active
Other names
Gastroenterology, Ltd
Organization subpart
No
Provider details
NPI number
Authorized official
MIKE SHADLEY (ADMINISTRATOR)
(309) 672-4980
Entity
Organization
Contact information
Practice address
1001 MAIN ST, SUITE 500A, PEORIA, IL 61606-1907
(309) 672-4980
(309) 671-2944
Mailing address
PO BOX 365, MORTON, IL 61550-0365
(309) 672-4980
(309) 671-2944
Taxonomy
Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
042006270
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
07215152
BLUE CROSS
IL
01
—
CE0700
RAILROAD MEDICARE
IL
Enumeration date
06/11/2006
Last updated
08/17/2020
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