Basic Information
| Provider Information | |||||||||
| NPI: | 1235124777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20021 MOHAWK TRL | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084816894 | ||||||||
| FaxNumber: | 7084814018 | ||||||||
| Practice Location | |||||||||
| Address1: | 8701 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197385510 | ||||||||
| FaxNumber: | 2197386714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01038358 | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 01038358 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100365270 | 05 | IN | MEDICAID |