1932191582 NPI number — ALAN N GORDON M.D.

Table of content: ALAN N GORDON M.D. (NPI 1932191582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932191582 NPI number — ALAN N GORDON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
ALAN
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1932191582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
04/10/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 PINE ST
Provider Second Line Business Mailing Address:
STE 760
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31201-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-633-6090
Provider Business Mailing Address Fax Number:
478-633-4080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 PINE ST
Provider Second Line Business Practice Location Address:
STE 760
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-633-6090
Provider Business Practice Location Address Fax Number:
478-633-4080
Provider Enumeration Date:
08/19/2005

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: 207VX0201X , with the licence number:  066740 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 278322300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 778269 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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