=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194381368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOSSETT GLOBAL HEALTH SOLUTIONS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2019
-----------------------------------------------------
Last Update Date | 07/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 BURWASH AVE
-----------------------------------------------------
City | SAVOY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61874-9510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-351-8040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1717 W KIRBY AVE # 246
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61821-5507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-351-8040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TOMMY KEITH GOSSETT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 217-351-8040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------