Basic Information
| Provider Information | |||||||||
| NPI: | 1861478885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | # 774560, 4560 SOLUTIONS CENTER | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606774005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609691950 | ||||||||
| FaxNumber: | 2609182137 | ||||||||
| Practice Location | |||||||||
| Address1: | 1316 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609254600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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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 | 207P00000X | 01041105A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 01041105A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000372544 | 01 | IN | BC/BS | OTHER | P00244450 | 01 | IN | RAILROAD MEDICARE | OTHER | 200033320A | 05 | IN | MEDICAID |