Provider Demographics
NPI:1235124777
Name:GORDON, GREGORY S (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:GORDON
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 1:20021 MOHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1125
Mailing Address - Country:US
Mailing Address - Phone:708-481-6894
Mailing Address - Fax:708-481-4018
Practice Address - Street 1:8701 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7035
Practice Address - Country:US
Practice Address - Phone:219-738-5510
Practice Address - Fax:219-738-6714
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038358207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100365270Medicaid
INE45601Medicare UPIN
IN237730CMedicare PIN