MEDICARE: MS. TERESA K GORDON III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	172A00000X	IL

General Provider Information

NPI Number	:	1023115920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERESA K GORDON III

Provider Business Mailing Address
First Line	:	3625 S LAKE PARK AVE
Second Line	:	#1107
City	:	CHICAGO
State	:	IL
Zip	:	60653-1468
Country	:	US
Telephone Number	:	773-538-1637
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 S LAKE PARK AVE
Second Line	:	#1107
City	:	CHICAGO
State	:	IL
Zip	:	60653-1468
Country	:	US
Telephone Number	:	773-538-1637
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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