Provider Demographics
NPI:1982682613
Name:GONNELLA, GEORGE R (DO)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:GONNELLA
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 1:300 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-933-4700
Mailing Address - Fax:630-933-4427
Practice Address - Street 1:300 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-933-4700
Practice Address - Fax:630-933-4427
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100718207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB1658OtherMEDICARE RAILROAD PTAN (GROUP)
ILP01248063OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
ILIL8618001OtherMEDICARE PTAN (INDIVIDUAL)
IL920540039OtherMEDICARE PTAN (INDIVIDUAL)
IL036100718Medicaid
IL920540OtherMEDICARE PTAN (GROUP)
ILIL8618OtherMEDICARE PTAN (GROUP)
ILIL2556002Medicare PIN
ILK13877Medicare PIN
ILIL8618001OtherMEDICARE PTAN (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)