Basic Information
| Provider Information | |||||||||
| NPI: | 1326000670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENNS | ||||||||
| FirstName: | GORDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4749 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975010227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895516 | ||||||||
| FaxNumber: | 5417895538 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975201552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412014000 | ||||||||
| FaxNumber: | 5414887434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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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 | 207P00000X | MD10734 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | C91177 | 01 | GROUP HEALTH | OTHER | 235101 | 05 | OR | MEDICAID | C91177 | 01 | PROVIDENCE HEALTH PLANS | OTHER | 023507000 | 01 | OR | BLUE CROSS BLUE SHIELD | OTHER | 930079056 | 01 | RAILROAD MEDICARE | OTHER | XPY185046 | 01 | MEDI - CAL | OTHER | 97520A009 | 01 | CHAMPUS | OTHER |