Healthcare Provider Details

I. General information

NPI: 1235124777
Provider Name (Legal Business Name): GREGORY S GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 BROADWAY
MERRILLVILLE IN
46410-7035
US

IV. Provider business mailing address

20021 MOHAWK TRL
OLYMPIA FIELDS IL
60461-1125
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-5510
  • Fax: 219-738-6714
Mailing address:
  • Phone: 708-481-6894
  • Fax: 708-481-4018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01038358
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01038358
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: