Provider Demographics
NPI:1821038159
Name:GORDON, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
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 1:1300 W BELMONT AVE
Mailing Address - Street 2:STE 313
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:773-562-4973
Mailing Address - Fax:
Practice Address - Street 1:200 S RITCHIE AVE
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1721
Practice Address - Country:US
Practice Address - Phone:844-291-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360935122084P0800X
WV263512084P0800X
TN540962084P0800X
NMTM2015-00372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400294134Medicare PIN