1215020755 NPI number — CARRIE A GORDON MD

Table of content: CARRIE A GORDON MD (NPI 1215020755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215020755 NPI number — CARRIE A GORDON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
CARRIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1215020755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 RIVERSIDE ST
Provider Second Line Business Mailing Address:
SUITE 6B
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103-1073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-621-2000
Provider Business Mailing Address Fax Number:
207-661-2033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
887 CONGRESS ST.
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-662-5522
Provider Business Practice Location Address Fax Number:
207-662-5527
Provider Enumeration Date:
10/02/2006

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: 208000000X , with the licence number:  MD16227 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0210X , with the licence number: MD16227 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30204313 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 407810099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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