Provider Demographics
NPI:1285682526
Name:GAMBON, PHILIP (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:GAMBON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5387
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-5387
Mailing Address - Country:US
Mailing Address - Phone:309-661-8823
Mailing Address - Fax:309-661-8801
Practice Address - Street 1:300 TENNEY ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3452
Practice Address - Country:US
Practice Address - Phone:309-853-5500
Practice Address - Fax:309-853-4150
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist