Unknown Individual – Emergency Medicine Physician, NPI 1114997947

Unknown Individual is a healthcare provider. based in Goreville, Illinois. specializing in Emergency Medicine Physician. The NPI Number for Unknown Individual is 1114997947

Main info

Organization
Inactive
60 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1114997947
Phone
(630) 885-0835
Address
525 LAKE SHORE DR S
Deactivation Date
5 December 2024

Doctor Profile

Medical School Name
OTHER
Secondary Phone
6182445500
Graduation Year
1966 (60 years ago)
PAC ID
5193771897
Group Practice PAC ID
7113167446
Professional Enrollment ID
I20050325000133
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience5
Completeness75
Years active:0State licenses:0Digital endpointsOther names

Provider Addresses for Unknown Individual

  • 525 LAKE SHORE DR S

    GOREVILLE, IL 629393178

    Phone: (630) 885-0835

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 62939)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 7113167446View full group profile
NameSpecialtyState
-IL
Emergency MedicinePA
Emergency MedicineIL
Emergency Medicine, Emergency Medicine, Family PracticeAR
-IL
Emergency Medicine, HospitalistIL
Emergency MedicineGA
Emergency Medicine, Hospice/Palliative CareVA
Family PracticeIL
Family PracticeTX

Reviews

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Frequently asked questions

What is the registry number for Unknown Individual?
The registry entry for Unknown Individual shows NPI 1114997947.
What happens when Unknown Individual's NPI is not active?
Public data lists Unknown Individual outside the active bucket for this identifier.
What services align with Unknown Individual's listing?
Unknown Individual's public classification highlights Emergency Medicine Physician. Clinical services aligned with this taxonomy classification.
What city is tied to Unknown Individual?
The directory associates Unknown Individual with Goreville, Illinois. Check all listed addresses for suites or satellite offices.
Why is information missing for Unknown Individual?
Providers choose how much contact data to publish. Missing fields do not mean the profile is fake.

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