Basic Information
| Provider Information | |||||||||
| NPI: | 1558308676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98 | ||||||||
| Address2: | TRI-COUNTY EMERGENCY PHYSICIANS | ||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169751845 | ||||||||
| FaxNumber: | 6169751870 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 W HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600101919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473819600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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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 | 207P00000X | 036085143 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036085143 | 05 | IL | MEDICAID | P00645039 | 01 | IL | RAILROAD MEDICARE | OTHER |