Healthcare Provider Details

I. General information

NPI: 1235268541
Provider Name (Legal Business Name): MARY L. GANNON M.D.,C.A.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 BUTTERFIELD RD SUITE 103 W
OAK BROOK IL
60523-1234
US

IV. Provider business mailing address

326 GRANDVIEW AVE
GLEN ELLYN IL
60137-5220
US

V. Phone/Fax

Practice location:
  • Phone: 630-981-4886
  • Fax:
Mailing address:
  • Phone: 630-981-4886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number036068239
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: