Provider Demographics
NPI:1982609103
Name:SIEGEL, GORDON J (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:J
Last Name:SIEGEL
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 1:3 E HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2887
Mailing Address - Country:US
Mailing Address - Phone:312-988-7777
Mailing Address - Fax:312-988-7838
Practice Address - Street 1:3 E HURON ST
Practice Address - Street 2:FL 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2887
Practice Address - Country:US
Practice Address - Phone:312-988-7777
Practice Address - Fax:312-988-7838
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053430207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059430Medicaid
ILD15001Medicare UPIN
IL371790Medicare ID - Type UnspecifiedMEDICARE