Healthcare Provider Details

I. General information

NPI: 1578911061
Provider Name (Legal Business Name): ANDREW C GORDON MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 4-710
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

240 E HURON ST STE 1-200 NORTHWESTERN MEDICINE MCGAW MEDICAL CENTER
CHICAGO IL
60611-2909
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-1791
  • Fax: 312-695-5645
Mailing address:
  • Phone: 312-503-7975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036.170625
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.072323
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: