Gabriels Pride Pediatrics
Organization Active NPI Pediatrics Physician · Ofallon, IL
NPI 1124285028 · NPPES record last updated May 19, 2008
Key facts
- NPI
- 1124285028
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatrics Physician 208000000X
- License
- 036095488 (IL)
- Legal business name
- GABRIELS PRIDE PEDIATRICS
- Practice address
- 1337 Park Plaza Drive
Suite 1
Ofallon, IL 62269-1777 - Phone
- (618) 624-7391
- Fax
- (618) 624-7392
- NPI assigned
- May 19, 2008
- Organization subpart
- No
Authorized official
- Name
- Dr. Thomas Edmund Levvaulh, MD
- Title
- MD President Owner
- Phone
- (618) 624-7391
National Provider Directory
Locations
1337 Park Plaza Dr
Ste 1
O Fallon, IL 62269
Phone (618) 624-7391
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | 036095488 | IL | Yes |
Addresses
Primary practice location
1337 Park Plaza Drive
Suite 1
Ofallon, IL 62269-1777
Mailing address
1337 Park Plaza Drive
Suite 1
Ofallon, IL 62269-1777
Phone (618) 624-7391
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036095488 | Medicaid | IL |
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All providers in Ofallon, IL · Pediatrics Physician in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 19, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.