Basic Information
| Provider Information | |||||||||
| NPI: | 1225016975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENTRY | ||||||||
| FirstName: | GEORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3853 | ||||||||
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| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616123853 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5409 N KNOXVILLE AVE | ||||||||
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| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096827750 | ||||||||
| FaxNumber: | 3096827786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 211015 | 01 | IL | HEALTHLINK | OTHER | 054573 | 01 | IL | HEALTH ALLIANCE | OTHER | IL0100 | 01 | IL | JOHN DEERE | OTHER | 036080941-1 | 05 | IL | MEDICAID | 1005156 | 01 | IL | ACR | OTHER | 0007222342 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |