Active NPI
Michael Gordon
- Community Health Worker
- Freeport, IL
National Provider Identifier
1275981805
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community Health Worker
- License
- ADS1101002
- Practice address
- 659 E Jefferson St
Freeport, IL 61032-6027 - Phone
- (815) 229-1999
- Fax
- (708) 478-6387
- NPI assigned
- May 24, 2016
- Last updated
- May 24, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Health Worker | 172V00000X | ADS1101002 | IL | Primary |
Addresses
Primary practice location
659 E Jefferson St
Freeport, IL 61032-6027
Mailing address
659 E Jefferson St
Freeport, IL 61032-6027
Phone (815) 229-1999
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ADS1101002 | Other | IL | ILLINOIS DEPARTENT OF AGING |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ADS1101002 | IL | MD | Community Health Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1464048000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1464048000000",
"number": "1275981805",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "659 E JEFFERSON ST",
"city": "FREEPORT",
"state": "IL",
"postal_code": "610326027",
"telephone_number": "815-229-1999",
"fax_number": "708-478-6387"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "659 E JEFFERSON ST",
"city": "FREEPORT",
"state": "IL",
"postal_code": "610326027",
"telephone_number": "815-229-1999",
"fax_number": "708-478-6387"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GORDON",
"first_name": "MICHAEL",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2016-05-24",
"last_updated": "2016-05-24",
"status": "A"
},
"taxonomies": [
{
"code": "172V00000X",
"taxonomy_group": "",
"desc": "Community Health Worker",
"state": "IL",
"license": "ADS1101002",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ILLINOIS DEPARTENT OF AGING",
"identifier": "ADS1101002",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Freeport, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.