Provider Demographics
NPI:1871793646
Name:ELITE GYNECOLOGY S.C.
Entity type:Organization
Organization Name:ELITE GYNECOLOGY S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:VIENNE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:815-942-0525
Mailing Address - Street 1:936 W US ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-8858
Mailing Address - Country:US
Mailing Address - Phone:815-942-0525
Mailing Address - Fax:815-942-3501
Practice Address - Street 1:936 W US ROUTE 6
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-8858
Practice Address - Country:US
Practice Address - Phone:815-942-0525
Practice Address - Fax:815-942-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082983207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3229984OtherBLUE CROSS BLUE SHIELD
IL3229984OtherBLUE CROSS BLUE SHIELD