Healthcare Provider Details

I. General information

NPI: 1457435786
Provider Name (Legal Business Name): BRADLEY JENNINGS GORDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRVING PARK RD STE 1
CHICAGO IL
60613-3099
US

IV. Provider business mailing address

PO BOX 14537
CHICAGO IL
60614-0537
US

V. Phone/Fax

Practice location:
  • Phone: 773-975-6775
  • Fax: 847-433-8294
Mailing address:
  • Phone: 847-433-8297
  • Fax: 847-433-8294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-069850
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: