1285630905 NPI number — DR. LEMUEL DURRELL GORDEN III M.D.

Table of content: DR. LEMUEL DURRELL GORDEN III M.D. (NPI 1285630905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285630905 NPI number — DR. LEMUEL DURRELL GORDEN III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDEN
Provider First Name:
LEMUEL
Provider Middle Name:
DURRELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
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:
1285630905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225B WINTON M BLOUNT LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36117-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-263-6228
Provider Business Mailing Address Fax Number:
334-265-9136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225B WINTON M BLOUNT LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36117-3507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-263-6228
Provider Business Practice Location Address Fax Number:
334-265-9136
Provider Enumeration Date:
06/27/2005

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: 174400000X , with the licence number:  22077 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00159247 . This is a "RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 009958605 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: G54042 . This is a "HEALTH SPRINGS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051521812 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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