Basic Information
| Provider Information | |||||||||
| NPI: | 1417190125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATHERS | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOSS | ||||||||
| OtherFirstName: | VALERIE | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 775985 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177706900 | ||||||||
| FaxNumber: | 3177706911 | ||||||||
| Practice Location | |||||||||
| Address1: | 17600 SHAMROCK BLVD STE 500A | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460747002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177706085 | ||||||||
| FaxNumber: | 7652984989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2009 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01072658A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P01456874 | 01 | RR MEDICARE | OTHER | 201171350 | 05 | IN | MEDICAID |