Provider Demographics
NPI:1962687913
Name:BEN GORDON CENTER
Entity Type:Organization
Organization Name:BEN GORDON CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-756-4875
Mailing Address - Street 1:599 PEARSON DR
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:IL
Mailing Address - Zip Code:60135-1355
Mailing Address - Country:US
Mailing Address - Phone:815-784-6029
Mailing Address - Fax:
Practice Address - Street 1:599 PEARSON DR
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135-1355
Practice Address - Country:US
Practice Address - Phone:815-784-6029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEN GORDON CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA0254001A261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid
IL207498Medicare PIN