Provider Demographics
NPI:1174512925
Name:GORDON, RANDALL JAY (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAY
Last Name:GORDON
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 1:2320 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2426
Mailing Address - Country:US
Mailing Address - Phone:708-388-5500
Mailing Address - Fax:708-388-5672
Practice Address - Street 1:2320 HIGH ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2426
Practice Address - Country:US
Practice Address - Phone:708-388-5500
Practice Address - Fax:708-388-5672
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070173Medicaid
IL160036380OtherRAILROAD MEDICARE
IL160036380Medicare PIN
IL036070173Medicaid
ILD16431Medicare UPIN