=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376582783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRANDON EMERGENCY PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2006
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8012 S CRANDON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-1124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-356-5362
-----------------------------------------------------
Fax | 773-768-8154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 42911
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19101-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-939-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JOSEPH H GATEWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-437-0817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------