Provider Demographics
NPI:1689850166
Name:COLETTE B. GORDON MD
Entity Type:Organization
Organization Name:COLETTE B. GORDON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TITI
Authorized Official - Middle Name:B
Authorized Official - Last Name:THACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-281-7835
Mailing Address - Street 1:2800 N SHERIDAN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6162
Mailing Address - Country:US
Mailing Address - Phone:773-281-7835
Mailing Address - Fax:773-281-8736
Practice Address - Street 1:2800 N SHERIDAN RD STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6162
Practice Address - Country:US
Practice Address - Phone:773-281-7835
Practice Address - Fax:773-281-8736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052490Medicaid
IL036052490Medicaid