Provider Demographics
NPI:1750499463
Name:GOMEZ, ROSE (MD,)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MD,
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Mailing Address - Street 1:875 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 3710
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1803
Mailing Address - Country:US
Mailing Address - Phone:312-951-2826
Mailing Address - Fax:312-951-2661
Practice Address - Street 1:7600 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-361-1616
Practice Address - Fax:708-361-1502
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL360568702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
0021609583OtherBLUE CROSS