Healthcare Provider Details

I. General information

NPI: 1154335917
Provider Name (Legal Business Name): KIM N GELKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W. PARK STREET NEONATOLOGY
URBANA IL
61801
US

IV. Provider business mailing address

P.O. BOX 6002
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3395
  • Fax:
Mailing address:
  • Phone: 217-326-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036078392
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: