1376653725 NPI number — JERRY P GORE CENTER FOR HOLISTIC MEDICINE LLC

Table of content: (NPI 1376653725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376653725 NPI number — JERRY P GORE CENTER FOR HOLISTIC MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY P GORE CENTER FOR HOLISTIC MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTER FOR HOLISTIC MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376653725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 SAUNDERS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERWOODS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60015-3835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-236-1701
Provider Business Mailing Address Fax Number:
847-236-1705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 SAUNDERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERWOODS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60015-3835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-236-1701
Provider Business Practice Location Address Fax Number:
847-236-1705
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORE
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
GENERAL MEDICINE AND PSYCHIATRY
Authorized Official Telephone Number:
847-236-1701

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  180004714 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 149003629 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 038010402 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 181000325 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 03659329 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 036053622 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 036053622 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0004932196 . This is a "BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0004927712 . This is a "ALISA COURTNEY LCPC BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0004927712 . This is a "CAROL GORE LCSW BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 038010402 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00004927712 . This is a "DR. DAVIS BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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