Healthcare Provider Details

I. General information

NPI: 1376653725
Provider Name (Legal Business Name): JERRY P GORE CENTER FOR HOLISTIC MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 SAUNDERS RD
RIVERWOODS IL
60015-3835
US

IV. Provider business mailing address

240 SAUNDERS RD
RIVERWOODS IL
60015-3835
US

V. Phone/Fax

Practice location:
  • Phone: 847-236-1701
  • Fax: 847-236-1705
Mailing address:
  • Phone: 847-236-1701
  • Fax: 847-236-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180004714
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149003629
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010402
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036053622
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number03659329
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number181000325
License Number StateIL
# 7
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036053622
License Number StateIL

VIII. Authorized Official

Name: DR. JERRY P GORE
Title or Position: GENERAL MEDICINE AND PSYCHIATRY
Credential: M.D.
Phone: 847-236-1701