MEDICARE: DR. OLENA GORDON M.D.

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	174400000X	Specialist
2	207Q00000X	Family Medicine Physician	036131766	IL

General Provider Information

NPI Number	:	1528309705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLENA GORDON M.D.

Provider Business Mailing Address
First Line	:	8937 W GOLF RD
Second Line	:
City	:	NILES
State	:	IL
Zip	:	60714-5812
Country	:	US
Telephone Number	:	847-375-9711
Fax Number	:	847-375-9732

Provider Business Practice Location Address
First Line	:	8937 W GOLF RD
Second Line	:
City	:	NILES
State	:	IL
Zip	:	60714-5812
Country	:	US
Telephone Number	:	847-375-9711
Fax Number	:

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

Provider Enumeration Date	:	03/12/2013
Last Update Date	:	12/17/2019

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