Healthcare Provider Details

I. General information

NPI: 1184850653
Provider Name (Legal Business Name): TRAVIS ANDRE GAYLES MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON STREET
JOLIET IL
60435-0000
US

IV. Provider business mailing address

1000 REMINGTON BLVD SUITE 100
BOLINGBROOK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax: 630-914-2469
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036131329
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036.131329
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: