Provider Demographics
NPI:1356341994
Name:GORDON, PAUL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JAMES
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 1:10604 SOUTHWEST HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2704
Mailing Address - Country:US
Mailing Address - Phone:708-346-4065
Mailing Address - Fax:708-423-5799
Practice Address - Street 1:10604 SOUTHWEST HWY STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415
Practice Address - Country:US
Practice Address - Phone:708-346-4065
Practice Address - Fax:708-423-5799
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046920A208G00000X
IL036095321208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095321Medicaid
IN200144230FMedicaid
IN200144230CMedicaid
MI1356341994Medicaid
IN200144230AMedicaid
IN200144230BMedicaid
IN200144230BMedicaid
IL036095321Medicaid
IL780001758Medicare PIN
IN408430HMedicare PIN
IL780000957Medicare PIN
IN200144230CMedicaid
IL262570Medicare PIN