Basic Information
| Provider Information | |||||||||
| NPI: | 1518158914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GURTLER | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6004 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618036004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 W. CURTIS ROAD | ||||||||
| Address2: | PEDIATRICS | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173656202 | ||||||||
| FaxNumber: | 2173261234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 209004436 | IL | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363L00000X | 209004436 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 041206785 | 05 | IL | MEDICAID | IL2613 | 01 | IL | MEDICARE GROUP PTAN | OTHER |