Provider Demographics
NPI:1457360695
Name:GIBLIN, JAMES G (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:GIBLIN
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 1:255 E LIBERTY DR APT 701
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5434
Mailing Address - Country:US
Mailing Address - Phone:630-865-2754
Mailing Address - Fax:
Practice Address - Street 1:675 N SAINT CLAIR ST STE 20-150
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5979
Practice Address - Country:US
Practice Address - Phone:312-694-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-090225208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
212210021Medicare PIN
K20463Medicare PIN
ILF07986Medicare UPIN