Provider Demographics
NPI:1184701922
Name:GILMORE, DAVID J (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:GILMORE
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 1:1333 N OAKLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3049
Mailing Address - Country:US
Mailing Address - Phone:954-377-2380
Mailing Address - Fax:
Practice Address - Street 1:333 N MADISON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436
Practice Address - Country:US
Practice Address - Phone:815-725-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL08500645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP73296Medicare UPIN
IL203876003Medicare PIN