Provider Demographics
NPI:1225015589
Name:GAYNOR, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:LUH - NORTH ENT., RM. 7604
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3304
Mailing Address - Fax:708-216-1259
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:LUH - NORTH ENT., RM. 7604
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3304
Practice Address - Fax:708-216-1259
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36060577207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36060577Medicaid
D93974Medicare UPIN
IL737431Medicare ID - Type Unspecified