=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710484332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JALEESA GILBERT-GORTMAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 07/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 MEMORIAL DR STE 220
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-474-1723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 MEMORIAL DR STE 220
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-474-1723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036154807
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------