1497044861 NPI number — MR. JERED STEVEN GAMBILL MSOTR/L

Table of content: MR. JERED STEVEN GAMBILL MSOTR/L (NPI 1497044861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497044861 NPI number — MR. JERED STEVEN GAMBILL MSOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMBILL
Provider First Name:
JERED
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSOTR/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497044861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 E IL HIGHWAY 15
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62864-5072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-241-7039
Provider Business Mailing Address Fax Number:
618-241-7039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 N 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-244-1302
Provider Business Practice Location Address Fax Number:
618-244-1302
Provider Enumeration Date:
04/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  056.009226 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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