Provider Demographics
NPI:1184767444
Name:GIDRON, ADI (MD)
Entity type:Individual
Prefix:
First Name:ADI
Middle Name:
Last Name:GIDRON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62311 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0623
Mailing Address - Country:US
Mailing Address - Phone:847-432-0300
Mailing Address - Fax:847-432-1203
Practice Address - Street 1:767 PARK AVE W
Practice Address - Street 2:SUITE 120
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2400
Practice Address - Country:US
Practice Address - Phone:847-432-0300
Practice Address - Fax:847-432-1203
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036110781207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110781Medicaid
IL036110781Medicaid
ILP00427788Medicare PIN
ILK38337Medicare PIN