Healthcare Provider Details

I. General information

NPI: 1265692123
Provider Name (Legal Business Name): CHERIE O. GAMBREL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHERIE O SIU MD

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14949 N US HIGHWAY 25 E STE. 4
CORBIN KY
40701-6285
US

IV. Provider business mailing address

PO BOX 1325
CORBIN KY
40702-1325
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-0305
  • Fax: 606-523-4368
Mailing address:
  • Phone: 606-526-8131
  • Fax: 606-528-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036128438
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125055005
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48556
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: