MEDICARE: DR. GORDON ANDREW FUQUA 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	2084P0800X	Psychiatry Physician	036041997	IL

General Provider Information

NPI Number	:	1881965309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON ANDREW FUQUA M.D.

Provider Business Mailing Address
First Line	:	2131 N CLARK ST
Second Line	:	# 9
City	:	CHICAGO
State	:	IL
Zip	:	60614-6188
Country	:	US
Telephone Number	:	312-623-8006
Fax Number	:

Provider Business Practice Location Address
First Line	:	2131 N CLARK ST
Second Line	:	# 9
City	:	CHICAGO
State	:	IL
Zip	:	60614-6188
Country	:	US
Telephone Number	:	312-623-8006
Fax Number	:

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

Provider Enumeration Date	:	01/13/2012
Last Update Date	:	01/13/2012

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