Provider Demographics
NPI:1548484629
Name:MIDMORE, GINA M (MD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:M
Last Name:MIDMORE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1275 E BELVIDERE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2082
Mailing Address - Country:US
Mailing Address - Phone:847-918-1462
Mailing Address - Fax:847-968-4311
Practice Address - Street 1:1275 E BELVIDERE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2082
Practice Address - Country:US
Practice Address - Phone:847-918-1462
Practice Address - Fax:847-968-4311
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2017-11-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4336972085R0202X
WI60516-202085R0202X
IN01073411A2085R0202X
IL036-1312702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021935800002Medicaid
128086Medicare PIN