Provider Demographics
NPI:1093344178
Name:GORDON, TALIA SIVAN
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:SIVAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734240
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4240
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:2500 W HIGGINS RD STE 1040
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-2049
Practice Address - Country:US
Practice Address - Phone:847-884-8096
Practice Address - Fax:847-490-0978
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023491390200000X
IL085009132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program