Provider Demographics
NPI:1932220829
Name:GERALD M DUFFY TRUST UW
Entity type:Organization
Organization Name:GERALD M DUFFY TRUST UW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRUSTEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PITTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-844-7111
Mailing Address - Street 1:202 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1920
Mailing Address - Country:US
Mailing Address - Phone:815-844-7111
Mailing Address - Fax:815-842-1061
Practice Address - Street 1:122 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1918
Practice Address - Country:US
Practice Address - Phone:815-844-7111
Practice Address - Fax:815-842-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL267183416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5390001OtherBLUE CROSS BLUE SHIELD
ILP00221706OtherRAILROAD MEDICARE
IL001803OtherHEALTH ALLIANCE
IL5390001OtherBLUE CROSS BLUE SHIELD
ILP00221706OtherRAILROAD MEDICARE
IL001803OtherHEALTH ALLIANCE
IL211449Medicare PIN