Individual
JAMIE GANCAYCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
781 S MCHENRY AVE, CRYSTAL LAKE, IL 60014-7444
(815) 459-2200
(815) 788-9263
Mailing address
781 S MCHENRY AVE, CRYSTAL LAKE, IL 60014-7444
(815) 459-2200
(815) 788-9263
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
036101835
IL
207Q00000X
Family Medicine Physician
Primary
036101835
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036101835
—
IL
01
—
04532206
BLUE CROSS BLUE SHIELD
IL
01
—
215184001
MEDICARE PTAN
IL
01
—
962341
MEDICARE GROUP PTAN
IL
Enumeration date
07/14/2005
Last updated
12/29/2021
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