Basic Information
| Provider Information | |||||||||
| NPI: | 1740574342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULLY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3231 EUCLID AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087832000 | ||||||||
| FaxNumber: | 7087833656 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 W SHARON RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452464137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137717213 | ||||||||
| FaxNumber: | 5137714356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 35130516 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.