Basic Information
| Provider Information | |||||||||
| NPI: | 1215931936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124A PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433479500 | ||||||||
| FaxNumber: | 8433479595 | ||||||||
| Practice Location | |||||||||
| Address1: | 124A PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433479500 | ||||||||
| FaxNumber: | 8433479595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9901642 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 21465 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4505 | 05 | SC | MEDICAID | 1244Q | 01 | NC | NC BLUE CROSS BLUE SHIELD | OTHER | 891244Q | 05 | NC | MEDICAID |