Basic Information
| Provider Information | |||||||||
| NPI: | 1184850653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAYLES | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | ANDRE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604400000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142417 | ||||||||
| FaxNumber: | 6309142499 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 MADISON STREET | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604350000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157257133 | ||||||||
| FaxNumber: | 6309142469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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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 | 208000000X | 036131329 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 036.131329 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036131329 | 05 | IL | MEDICAID |