Healthcare Provider Details

I. General information

NPI: 1619282233
Provider Name (Legal Business Name): PATRICK BRIAN GIBBONS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 N CLARK ST
CHICAGO IL
60626-4097
US

IV. Provider business mailing address

6500 N CLARK ST
CHICAGO IL
60626-4097
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8664
Mailing address:
  • Phone: 773-388-1600
  • Fax: 708-422-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125057692
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.132207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: