MEDICARE: DR. HENRY GORDON DAVIS III MD

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	207V00000X	Obstetrics & Gynecology Physician	036061440	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31602229	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1720065642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY GORDON DAVIS III MD

Provider Business Mailing Address
First Line	:	2500 W HIGGINS RD
Second Line	:	640
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-7220
Country	:	US
Telephone Number	:	847-884-0906
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W HIGGINS RD
Second Line	:	SUITE 640
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-7220
Country	:	US
Telephone Number	:	847-884-0906
Fax Number	:	847-884-0994

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

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	05/10/2010

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