Provider Demographics
NPI:1417974973
Name:GORDON, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
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 1:1000 CENTRAL ST STE 730
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1779
Mailing Address - Country:US
Mailing Address - Phone:847-663-8410
Mailing Address - Fax:847-570-1865
Practice Address - Street 1:1000 CENTRAL ST STE 730
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-663-8410
Practice Address - Fax:847-570-1865
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110124207P00000X, 207RC0000X
IL036110124207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110124Medicaid
IL036110124Medicaid
ILK12219Medicare PIN