Provider Demographics
NPI:1720187453
Name:GANNON, PATRICK GERARD (DO)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:GERARD
Last Name:GANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 BRITTANY CT
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-5161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 BETHANY RD
Practice Address - Street 2:3251 COMMERCE DRIVE
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4939
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL237087041;651249587OtherTAX ID NUMBER
IL021940024;0031940152OtherBCBS PRVIDER #