Basic Information
| Provider Information | |||||||||
| NPI: | 1508898206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22285 N. PEPPER ROAD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478822538 | ||||||||
| Practice Location | |||||||||
| Address1: | 22285 N. PEPPER ROAD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478822538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036106343 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0361063431 | 05 | IL | MEDICAID |