Provider Demographics
NPI:1154485241
Name:JANIS A GUMPEL MD SC
Entity Type:Organization
Organization Name:JANIS A GUMPEL MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUMPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD SC
Authorized Official - Phone:708-923-7600
Mailing Address - Street 1:12255 S 80TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1270
Mailing Address - Country:US
Mailing Address - Phone:708-923-7600
Mailing Address - Fax:708-923-7605
Practice Address - Street 1:12255 S 80TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1270
Practice Address - Country:US
Practice Address - Phone:708-923-7600
Practice Address - Fax:708-923-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038295174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL488730Medicare PIN