Healthcare Provider Details

I. General information

NPI: 1669979456
Provider Name (Legal Business Name): MOLLY ETLING GILBERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E TREMONT ST
HILLSBORO IL
62049-1912
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-532-6911
  • Fax: 217-532-6237
Mailing address:
  • Phone: 217-528-7541
  • Fax: 217-525-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.156491
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01083098A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: