Provider Demographics
NPI:1558333633
Name:GERBERDING, ALLEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:G
Last Name:GERBERDING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1515 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1157
Mailing Address - Country:US
Mailing Address - Phone:217-243-6454
Mailing Address - Fax:217-243-1388
Practice Address - Street 1:1515 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1150
Practice Address - Country:US
Practice Address - Phone:217-243-6454
Practice Address - Fax:217-243-1388
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057587Medicaid
IL06900103OtherBCBS
IL06900103OtherBCBS
ILC44705Medicare UPIN