Provider Demographics
NPI:1518158914
Name:GURTLER, JODY K (NP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:K
Last Name:GURTLER
Suffix:
Gender:F
Credentials:NP
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 6004
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6004
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1701 W. CURTIS ROAD
Practice Address - Street 2:PEDIATRICS
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-365-6202
Practice Address - Fax:217-326-1234
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004436163WP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041206785Medicaid
ILIL2613OtherMEDICARE GROUP PTAN
ILIL2613045Medicare PIN
ILIL3270048Medicare PIN
ILIL2613OtherMEDICARE GROUP PTAN