Basic Information
| Provider Information | |||||||||
| NPI: | 1134235955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMERON | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629181923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 404 S LEWIS LN | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085001260 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 370966854002 | 05 | IL | MEDICAID | 085001260 | 01 | IL | STATE LICENSE NUMBER | OTHER | CF3444 | 01 | IL | MEDICARE RR | OTHER | 370966854006 | 05 | IL | MEDICAID | 370966854005 | 05 | IL | MEDICAID | 132566 | 01 | IL | HEALTH ALLIANCE | OTHER | 370966854015 | 05 | IL | MEDICAID |