Provider Demographics
NPI:1609514801
Name:GATEWAY FAMILY SERVICES OF ILLINOIS
Entity type:Organization
Organization Name:GATEWAY FAMILY SERVICES OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REMOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-488-8006
Mailing Address - Street 1:7757 US ROUTE 136
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:IL
Mailing Address - Zip Code:61865-3047
Mailing Address - Country:US
Mailing Address - Phone:217-488-8006
Mailing Address - Fax:217-987-6386
Practice Address - Street 1:7757 US ROUTE 136
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:IL
Practice Address - Zip Code:61865-3047
Practice Address - Country:US
Practice Address - Phone:217-488-8006
Practice Address - Fax:217-987-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty