Provider Demographics
NPI:1376653725
Name:JERRY P GORE CENTER FOR HOLISTIC MEDICINE LLC
Entity Type:Organization
Organization Name:JERRY P GORE CENTER FOR HOLISTIC MEDICINE LLC
Other - Org Name:CENTER FOR HOLISTIC MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MEDICINE AND PSYCHIATRY
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-236-1701
Mailing Address - Street 1:240 SAUNDERS RD
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3835
Mailing Address - Country:US
Mailing Address - Phone:847-236-1701
Mailing Address - Fax:847-236-1705
Practice Address - Street 1:240 SAUNDERS RD
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3835
Practice Address - Country:US
Practice Address - Phone:847-236-1701
Practice Address - Fax:847-236-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004714101Y00000X
IL149003629104100000X
MN038010402111N00000X
IL181000325174400000X
IL03659329207R00000X
IL0360536222084P0800X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004932196OtherBC/BS
IL0004927712OtherALISA COURTNEY LCPC BC/BS
IL0004927712OtherCAROL GORE LCSW BC/BS
IL038010402Medicaid
IL00004927712OtherDR. DAVIS BC/BS
IL00004927712OtherDR. DAVIS BC/BS
IL0004927712OtherCAROL GORE LCSW BC/BS