Healthcare Provider Details

I. General information

NPI: 1104189802
Provider Name (Legal Business Name): STEVE GENTRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 10/18/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W. CURTIS RD.
CHAMPAIGN IL
61822-9678
US

IV. Provider business mailing address

611 W. PARK ST. FAPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6201
  • Fax: 217-326-4003
Mailing address:
  • Phone: 217-902-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036136706
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: