1154310761 NPI number — DR. GORDON A PAGE JR. M.D.

Table of content: DR. GORDON A PAGE JR. M.D. (NPI 1154310761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154310761 NPI number — DR. GORDON A PAGE JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAGE
Provider First Name:
GORDON
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.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:
1154310761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2177
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34265-2177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-494-3535
Provider Business Mailing Address Fax Number:
836-491-4328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
888 N ROBERT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34266-9580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-494-8401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2005

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: 207Q00000X , with the licence number:  GP041179 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME97222 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1729834 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2771641 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".