Healthcare Provider Details

I. General information

NPI: 1669406054
Provider Name (Legal Business Name): DARREL C GUMM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 N KNOXVILLE AVE
PEORIA IL
61614
US

IV. Provider business mailing address

5405 N KNOXVILLE AVE
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4410
  • Fax: 309-589-6530
Mailing address:
  • Phone: 309-691-4410
  • Fax: 309-589-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036064999
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: