Healthcare Provider Details

I. General information

NPI: 1477502714
Provider Name (Legal Business Name): MARTIN J GORBIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 319
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1525 E 55TH ST STE 319
CHICAGO IL
60615-5512
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7030
  • Fax:
Mailing address:
  • Phone: 312-942-7030
  • Fax: 773-388-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036-071955
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: