Provider Demographics
NPI:1306027412
Name:ROSE GOMEZ, M.D.,P.C.
Entity Type:Organization
Organization Name:ROSE GOMEZ, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PC
Authorized Official - Phone:708-361-1616
Mailing Address - Street 1:875 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 3710
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1803
Mailing Address - Country:US
Mailing Address - Phone:312-951-2826
Mailing Address - Fax:
Practice Address - Street 1:7600 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-361-1616
Practice Address - Fax:708-361-1502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARENT ORGANIZATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-16
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36056870261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021609583OtherBLUE CROSS
IL670061Medicare PIN