Basic Information
| Provider Information | |||||||||
| NPI: | 1932373255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUMP | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | CORBLY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAY ST STE 1105 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025831697 | ||||||||
| FaxNumber: | 5025832120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 036123127 | IL | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 43547 | KY | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000052155Z | 01 | KY | HUMANA - NNIKY | OTHER | 000000675413 | 01 | KY | ANTHEM - NNIKY | OTHER | 289438 | 01 | KY | CIGNA - NNIKY | OTHER | 7100128470 | 05 | KY | MEDICAID | 50029987 | 01 | KY | PASSPORT & PASSPORT ADVANTAGE - NNIKY | OTHER | 201019170 | 05 | IN | MEDICAID | 118047 | 01 | KY | SIHO - NNIKY | OTHER |