Provider Demographics
NPI:1972695633
Name:GORE, JERRY P (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:P
Last Name:GORE
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 1:240 SAUNDERS RD
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3835
Mailing Address - Country:US
Mailing Address - Phone:847-236-1701
Mailing Address - Fax:847-236-1705
Practice Address - Street 1:240 SAUNDERS RD
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3835
Practice Address - Country:US
Practice Address - Phone:847-236-1701
Practice Address - Fax:847-236-1705
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004932196OtherBC/BS
ILL66522Medicare PIN
IL0004932196OtherBC/BS