Provider Demographics
NPI:1891987988
Name:GUMMERMAN, GARY
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:GUMMERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E CARPENTER ST
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5185
Mailing Address - Country:US
Mailing Address - Phone:217-744-8000
Mailing Address - Fax:
Practice Address - Street 1:320 E CARPENTER ST
Practice Address - Street 2:SUITE 1-B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5185
Practice Address - Country:US
Practice Address - Phone:217-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7321225100000X
IL70015971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist