1295371656 NPI number — KAITLYN ELISE GORDON

Table of content: KAITLYN ELISE GORDON (NPI 1295371656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295371656 NPI number — KAITLYN ELISE GORDON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
KAITLYN
Provider Middle Name:
ELISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1295371656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108-1633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-647-5299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 E MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48109-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-936-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2019

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: 363L00000X , with the licence number:  4704311304 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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