MEDICARE: DR. JON R GILDEA DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	5101014660	MI
2	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	5101014660	MI
3	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	10620	MT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00158334	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	JG014660	OTHER	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1548243439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON R GILDEA DO

Provider Business Mailing Address
First Line	:	DEPT CH 17767
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60055-0001
Country	:	US
Telephone Number	:	800-968-6866
Fax Number	:

Provider Business Practice Location Address
First Line	:	2946 STARLIGHT DRIVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803
Country	:	US
Telephone Number	:	406-240-2148
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	03/08/2021

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Directions to “ DR. JON R GILDEA DO” Practice Location

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