Provider Demographics
NPI:1639143373
Name:GOBER, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GOBER
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 1:4250 N MARINE DR
Mailing Address - Street 2:SUITE 236
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1744
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:
Practice Address - Street 1:4250 N MARINE DR
Practice Address - Street 2:SUITE 236
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1744
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD12773Medicare UPIN
IL383980Medicare ID - Type Unspecified