Basic Information
| Provider Information | |||||||||
| NPI: | 1548294184 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PRENDERGAST | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 E. 1ST STREET | ||||||||
| Address2: | KATHERINE SHAW BETHEA HOSPITAL | ||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855629 | ||||||||
| FaxNumber: | 8152855634 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E. 1ST STREET | ||||||||
| Address2: | KATHERINE SHAW BETHEA HOSPITAL | ||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855629 | ||||||||
| FaxNumber: | 8152855634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036102246 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 036-102246 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036102246 | 05 | IL | MEDICAID | F400261482 | 01 | IL | MEDICARE PTAN | OTHER | 0222075 | 01 | IL | BLUE CROSS GROUP NUMER | OTHER |