Provider Demographics
NPI:1194796409
Name:GERGANS, GREGORY ALLEN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:GERGANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2503
Mailing Address - Country:US
Mailing Address - Phone:773-732-3289
Mailing Address - Fax:
Practice Address - Street 1:2221 GRANT ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2503
Practice Address - Country:US
Practice Address - Phone:773-732-3289
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF98874Medicare UPIN