Provider Demographics
NPI:1871750711
Name:CARMEN GNATENCO M.D., S.C.
Entity type:Organization
Organization Name:CARMEN GNATENCO M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:GNATENCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-742-8926
Mailing Address - Street 1:6400 W COLLEGE DR STE 600
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1900
Mailing Address - Country:US
Mailing Address - Phone:708-389-3224
Mailing Address - Fax:708-389-3587
Practice Address - Street 1:4938 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2504
Practice Address - Country:US
Practice Address - Phone:708-425-4662
Practice Address - Fax:708-452-4692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115290Medicaid
IL1639587OtherBCBS
ILP00692896OtherRAILROAD MEDICARE
IL1639587OtherBCBS
IL216713Medicare PIN