Basic Information
Provider Information
NPI: 1003005620
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GENTEMAN
FirstName: MICHELLE
MiddleName: REBECCA
NamePrefix: MISS
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1713 PINE ST
Address2:  
City: HIGHLAND
State: IL
PostalCode: 622492523
CountryCode: US
TelephoneNumber: 6186546789
FaxNumber:  
Practice Location
Address1: 1713 PINE ST
Address2:  
City: HIGHLAND
State: IL
PostalCode: 622492523
CountryCode: US
TelephoneNumber: 6186546789
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/19/2007
LastUpdateDate: 10/19/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X  Y Other Service ProvidersSpecialist 

No ID Information.


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