=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972551513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD LOFTHOUSE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 02/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 W BOUGHTON RD STE F1
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-1984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-410-2448
-----------------------------------------------------
Fax | 630-410-8327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 278
-----------------------------------------------------
City | CLARENDON HLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60514-0278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-410-2448
-----------------------------------------------------
Fax | 630-410-8327
-----------------------------------------------------
=====================================================
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 | 36058630
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------