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General NPI Number Information
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NPI Number | 1902134778
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Entity Type | Organization
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Legal Business Name | PRUDENCE L. GOURGUECHON, M.D. S.C.
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Dates
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Enumeration Date | 12/06/2009
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Last Update Date | 12/06/2009
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Provider Practice Location Address
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Address Line | 1454 W FARRAGUT AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2104
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Country | US
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Telephone | 773-878-8082
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Fax |
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Provider Business Mailing Address
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Address Line | 1454 W FARRAGUT AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2104
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Country | US
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Telephone | 773-878-8082
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PRUDENCE L GOURGUECHON
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Credential | MD
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Telephone | 773-878-8082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 102L00000X
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Taxonomy Name | Psychoanalyst
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License Number | 036062459
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License Number State | IL
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