Provider Demographics
NPI:1326143942
Name:GORELICK, JEFFREY B (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:GORELICK
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 1:2626 N 76TH STREET
Mailing Address - Street 2:
Mailing Address - City:WALLWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:414-771-2707
Mailing Address - Fax:
Practice Address - Street 1:2626 N 76TH STREET
Practice Address - Street 2:
Practice Address - City:WALLWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-771-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI249282081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B53165Medicare UPIN