Provider Demographics
NPI:1114955697
Name:GERSTEIN, MORDECAI M (MD)
Entity Type:Individual
Prefix:DR
First Name:MORDECAI
Middle Name:M
Last Name:GERSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 W LUNT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2919
Mailing Address - Country:US
Mailing Address - Phone:773-274-2678
Mailing Address - Fax:773-274-2697
Practice Address - Street 1:2949 W LUNT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2919
Practice Address - Country:US
Practice Address - Phone:773-274-2678
Practice Address - Fax:773-274-2697
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076565207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000526820OtherANTHEM
INP00632888OtherRAILROAD MEDICARE
ILD15741Medicare UPIN
IN070860A2Medicare PIN