Provider Demographics
NPI:1134235955
Name:CAMERON, GERALD R (PA-C)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:R
Last Name:CAMERON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1923
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:
Practice Address - Street 1:404 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854002Medicaid
IL085001260OtherSTATE LICENSE NUMBER
ILCF3444OtherMEDICARE RR
IL370966854006Medicaid
IL370966854005Medicaid
IL132566OtherHEALTH ALLIANCE
IL370966854015Medicaid
IL370966854006Medicaid
ILCF3444OtherMEDICARE RR
IL640701Medicare Oscar/Certification
IL141848Medicare Oscar/Certification
IL085001260OtherSTATE LICENSE NUMBER