Provider Demographics
NPI:1942219324
Name:GAUEN, RALPH E (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:E
Last Name:GAUEN
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:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-670-2424
Mailing Address - Fax:217-670-2809
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-6722
Practice Address - Fax:217-391-0392
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052267Medicaid
IL036052267Medicaid
IL004425OtherHEALTH ALLIANCE
IL036052267OtherIL STATE LICENSE
ILCD7143OtherRR MEDICARE GROUP
ILC37847Medicare UPIN
IL133586700OtherACS-OWCP
IL14D0949277OtherCLIA CERT
IL224479OtherPERSONAL CARE
IL08421024OtherBC/BS
IL126328OtherHEALTHLINK
ILP00145050OtherRR MEDICARE PIN
IL6394POtherCATERPILLAR