1023184694 NPI number — DR. GORDON ANTHONY SCHULZ PSY D

Table of content: DR. GORDON ANTHONY SCHULZ PSY D (NPI 1023184694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023184694 NPI number — DR. GORDON ANTHONY SCHULZ PSY D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHULZ
Provider First Name:
GORDON
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1023184694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35318 EAGLE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60678-1353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20121 CRAWFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA FIELDS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60461-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-756-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  20042090A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 071005343 , 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: 0090001287 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 4673170001 . This is a "DMERC GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00439470/CK6882 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL5686039 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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