1114105665 NPI number — MAXIE GORDON MD & ASSOCIATES, PLLC

Table of content: (NPI 1114105665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114105665 NPI number — MAXIE GORDON MD & ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXIE GORDON MD & ASSOCIATES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1114105665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
590 SPRINGRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39056-5606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-488-8101
Provider Business Mailing Address Fax Number:
662-287-5678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 SPRINGRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-488-8101
Provider Business Practice Location Address Fax Number:
662-287-5678
Provider Enumeration Date:
02/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALTON
Authorized Official First Name:
TEANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS OPERATIONS
Authorized Official Telephone Number:
601-488-8101

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  9801288 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08723392 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com