Provider Demographics
NPI:1548270861
Name:LUTCHMAN, GORDON D
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:D
Last Name:LUTCHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0791
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:224-235-4652
Practice Address - Street 1:8352 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1909
Practice Address - Country:US
Practice Address - Phone:215-809-1445
Practice Address - Fax:224-235-4652
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04510100208600000X
NY164843-12086S0102X
PAMD456515208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01034257Medicaid
NJ0533033Medicaid
PA1031022030001Medicaid