Provider Demographics
NPI:1497729537
Name:GAWNE, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:GAWNE
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 1:885 ROOSEVELT RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-384-6330
Mailing Address - Fax:630-384-6339
Practice Address - Street 1:885 ROOSEVELT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-384-6330
Practice Address - Fax:630-384-6339
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36071083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071083Medicaid
IL487450005OtherMEDICARE PTAN (INDIVIDUAL)
ILF400163079OtherMEDICARE PTAN (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)
IL487450Medicare PIN
IL487450005OtherMEDICARE PTAN (INDIVIDUAL)