Basic Information
Provider Information | |||||||||
NPI: | 1053342956 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GERNON | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15977 COLLECTION CENTER DR | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606930159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007375654 | ||||||||
FaxNumber: | 4238555046 | ||||||||
Practice Location | |||||||||
Address1: | 7301 E FRONTAGE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SHAWNEE MISSION | ||||||||
State: | KS | ||||||||
PostalCode: | 662041654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9137891940 | ||||||||
FaxNumber: | 9133844093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 05/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-31472 | KS | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00410901 | 01 |   | RR MEDICARE | OTHER | 3591024 | 01 |   | BCBSKC | OTHER | 75316418400 | 01 |   | CHP | OTHER | 9339760006 | 01 |   | CIGNA | OTHER |