=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093022360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA GEBHART RN,CDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2010
-----------------------------------------------------
Last Update Date | 09/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3722 S. HARLEM AVE. SUITE 202
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-783-6980
-----------------------------------------------------
Fax | 708-783-6979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3722 S. HARLEM AVE. SUITE 202
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-783-6980
-----------------------------------------------------
Fax | 708-783-6979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WD0400X
-----------------------------------------------------
Taxonomy Name | Diabetes Educator Registered Nurse
-----------------------------------------------------
License Number | 041-155749
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------