Basic Information
| Provider Information | |||||||||
| NPI: | 1043285026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSSEAU | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4501 N WINCHESTER AVE | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732500500 | ||||||||
| FaxNumber: | 7732500497 | ||||||||
| Practice Location | |||||||||
| Address1: | 4501 N WINCHESTER AVE | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732500500 | ||||||||
| FaxNumber: | 7732500497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 10/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 036 085338 | IL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0360853381 | 05 | IL | MEDICAID |