Basic Information
| Provider Information | |||||||||
| NPI: | 1366480170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLUCKMAN | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 FEEHANVILLE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600566036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478233185 | ||||||||
| FaxNumber: | 8478233318 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 FEEHANVILLE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600566036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478233185 | ||||||||
| FaxNumber: | 8478233318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036090439 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036090439 | 05 | IL | MEDICAID |