Provider Demographics
NPI:1467841809
Name:KISHWAUKEE CORPORATE HEALTH @MOI
Entity type:Organization
Organization Name:KISHWAUKEE CORPORATE HEALTH @MOI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:G
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-754-4882
Mailing Address - Street 1:2111 MIDLANDS CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:181-575-4488
Mailing Address - Fax:
Practice Address - Street 1:2111 MIDLANDS CT
Practice Address - Street 2:SUITE 201
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:181-575-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077643261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1255594545OtherWORKER'S COMP