Healthcare Provider Details

I. General information

NPI: 1972695633
Provider Name (Legal Business Name): JERRY P GORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 12/28/2007
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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: