Healthcare Provider Details

I. General information

NPI: 1346236304
Provider Name (Legal Business Name): KEITH R GABRIEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-1041
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-6535
  • Fax: 217-757-6536
Mailing address:
  • Phone: 217-545-7578
  • Fax: 217-545-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036078399
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number036-078399
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: