Healthcare Provider Details

I. General information

NPI: 1124673256
Provider Name (Legal Business Name): GRETCHEN GINDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 INDUSTRY RD
BRIDGEPORT IL
62417-2442
US

IV. Provider business mailing address

800 E LOCUST ST
OLNEY IL
62450-2553
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-7340
  • Fax:
Mailing address:
  • Phone: 618-395-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209019732
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: