Provider Demographics
NPI:1457435786
Name:GORDON, BRADLEY JENNINGS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JENNINGS
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14537
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-0537
Mailing Address - Country:US
Mailing Address - Phone:847-433-8297
Mailing Address - Fax:847-433-8294
Practice Address - Street 1:850 W IRVING PARK RD STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3099
Practice Address - Country:US
Practice Address - Phone:773-975-6775
Practice Address - Fax:847-433-8294
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0698502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069850Medicaid
IL31603528OtherBLUE CROSS/BLUE SHIELD
IL036069850Medicaid