=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679599518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERARDO GUTIERREZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 01/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7245 RAIDER RD
-----------------------------------------------------
City | BONNE TERRE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63628-3767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-468-4186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 REMITT DRIVE LOCKBOX 1900
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60675-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-916-5259
-----------------------------------------------------
Fax | 231-922-4030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 01046504A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 2001022240
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------