Healthcare Provider Details

I. General information

NPI: 1437837762
Provider Name (Legal Business Name): MALCOLM GEBAUER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S CENTRAL AVE
CHICAGO IL
60644-5059
US

IV. Provider business mailing address

727 W MADISON ST APT 3603
CHICAGO IL
60661-2579
US

V. Phone/Fax

Practice location:
  • Phone: 530-410-7494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.083009
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125.083009
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: