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General NPI Number Information
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NPI Number | 1689850166
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Entity Type | Organization
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Legal Business Name | COLETTE B. GORDON MD
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Dates
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Enumeration Date | 01/15/2008
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Last Update Date | 02/14/2008
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Provider Practice Location Address
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Address Line | 2800 N SHERIDAN RD STE 101
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City | CHICAGO
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State | IL
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Zip | 60657-6162
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Country | US
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Telephone | 773-281-7835
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Fax | 773-281-8736
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Provider Business Mailing Address
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Address Line | 2800 N SHERIDAN RD STE 101
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City | CHICAGO
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State | IL
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Zip | 60657-6162
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Country | US
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Telephone | 773-281-7835
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Fax | 773-281-8736
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Authorized Official
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Title or Position | BILLER
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Name | TITI B THACH
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Credential |
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Telephone | 773-281-7835
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036052490
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License Number State | IL
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