Basic Information
| Provider Information | |||||||||
| NPI: | 1326054263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASKELL | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3141 NW 63RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056071318 | ||||||||
| FaxNumber: | 4056071326 | ||||||||
| Practice Location | |||||||||
| Address1: | 549 E FAIR ST | ||||||||
| Address2: | BLOOMBURG HOSPITAL | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173872115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | MD37149E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 50060527 | 01 | PA | CAPITAL BLUE CROSS | OTHER | HA40669 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0011180410002 | 05 | PA | MEDICAID |