Healthcare Provider Details

I. General information

NPI: 1851523377
Provider Name (Legal Business Name): JILL L GORSUCH DO, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL L COLLINS DO, MPH

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N SAINT JOSEPH AVE SUITE 100
NILES MI
49120-2203
US

IV. Provider business mailing address

42 N SAINT JOSEPH AVE SUITE 100
NILES MI
49120-2203
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-6696
  • Fax: 269-684-5286
Mailing address:
  • Phone: 269-684-6696
  • Fax: 269-684-5286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberL1593656
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101018409
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number006332
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: