Provider Demographics
NPI:1417241944
Name:GENTILE, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GENTILE
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 1:22285 N PEPPER RD STE 311
Mailing Address - Street 2:
Mailing Address - City:LAKE BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2541
Mailing Address - Country:US
Mailing Address - Phone:847-382-4410
Mailing Address - Fax:815-968-9453
Practice Address - Street 1:22285 N PEPPER RD STE 311
Practice Address - Street 2:
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2541
Practice Address - Country:US
Practice Address - Phone:847-382-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55286207R00000X
IL036.134432207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN110015513Medicare PIN