MEDICARE: SARA M GOTHERIDGE MD LLC

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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1295351062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SARA M GOTHERIDGE MD LLC

Provider Business Mailing Address
First Line	:	2412 LAWNDALE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1854
Country	:	US
Telephone Number	:	312-608-4996
Fax Number	:	877-421-1846

Provider Business Practice Location Address
First Line	:	630 DAVIS ST STE 301
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4480
Country	:	US
Telephone Number	:	312-640-7731
Fax Number	:	877-421-1846

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SARA MARGARET GOTHERIDGE
Credential	:	MD
Telephone Number	:	312-640-7731

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	06/17/2020

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