Provider Demographics
NPI:1548294184
Name:PRENDERGAST, GAIL E (MD)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:E
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E. 1ST STREET
Mailing Address - Street 2:KATHERINE SHAW BETHEA HOSPITAL
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-285-5629
Mailing Address - Fax:815-285-5634
Practice Address - Street 1:403 E. 1ST STREET
Practice Address - Street 2:KATHERINE SHAW BETHEA HOSPITAL
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5629
Practice Address - Fax:815-285-5634
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102246208M00000X
IL036-102246208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102246Medicaid
ILF400261482OtherMEDICARE PTAN
IL0222075OtherBLUE CROSS GROUP NUMER
ILF400261482Medicare UPIN
IL206147Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER