Provider Demographics
NPI:1003832189
Name:CARGILL, JERRY WARD (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WARD
Last Name:CARGILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 E GRANT HWY
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-3346
Mailing Address - Country:US
Mailing Address - Phone:815-568-7313
Mailing Address - Fax:815-568-0151
Practice Address - Street 1:556 E GRANT HWY
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3346
Practice Address - Country:US
Practice Address - Phone:815-568-7313
Practice Address - Fax:815-568-0151
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44585Medicare UPIN
ILL72418Medicare ID - Type Unspecified