Healthcare Provider Details

I. General information

NPI: 1467448969
Provider Name (Legal Business Name): TODD A GEPHART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 EAST MAIN STREET SUITE 105
EAST DUNDEE IL
60118-1642
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 847-428-3322
  • Fax: 847-428-0472
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-095773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: