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General NPI Number Information
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NPI Number | 1467841809
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Entity Type | Organization
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Legal Business Name | KISHWAUKEE CORPORATE HEALTH @MOI
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Dates
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Enumeration Date | 01/22/2015
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Last Update Date | 01/22/2015
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Provider Practice Location Address
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Address Line | 2111 MIDLANDS CT SUITE 201
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City | SYCAMORE
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State | IL
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Zip | 60178-3125
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Country | US
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Telephone | 181-575-4488
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Fax |
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Provider Business Mailing Address
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Address Line | 2111 MIDLANDS CT SUITE 201
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City | SYCAMORE
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State | IL
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Zip | 60178
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Country | US
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Telephone | 181-575-4488
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. PATRICK G GANNON
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Credential | DO
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Telephone | 815-754-4882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number | 036-077643
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License Number State | IL
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