Provider Demographics
NPI:1215994843
Name:LEVISAY, GERALD LEE (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:LEE
Last Name:LEVISAY
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 1:600 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1512
Mailing Address - Country:US
Mailing Address - Phone:815-664-5367
Mailing Address - Fax:815-664-5204
Practice Address - Street 1:600 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1512
Practice Address - Country:US
Practice Address - Phone:815-664-5367
Practice Address - Fax:815-664-5367
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3651002208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03651002Medicaid
ILL86561Medicare PIN
IL03651002Medicaid