Basic Information
| Provider Information | |||||||||
| NPI: | 1548290901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLONE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GALENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157771340 | ||||||||
| FaxNumber: | 8157767274 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GALENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157771340 | ||||||||
| FaxNumber: | 8157767274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11013121A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036123588 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11013121A | 01 | IN | LICENSE | OTHER | 036123588 | 01 | IL | LICENSE | OTHER |