Individual
GWEN R GOLA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
19841 WOLF RD, MOKENA, IL 60448-1315
(708) 479-0320
(708) 479-3695
Mailing address
205 W WACKER DR, SUITE 1020, CHICAGO, IL 60606-1216
(312) 640-0329
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
070013181
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1619980
BCBS OF IL
IL
01
—
567700
MEDICARE GROUP NUMBER
IL
01
—
568080
MEDICARE GROUP NUMBER
IL
01
—
568150
MEDICARE GROUP NUMBER
IL
Enumeration date
07/12/2007
Last updated
12/02/2008
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