Basic Information
| Provider Information | |||||||||
| NPI: | 1649243890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9 OLD PLANK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120653107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183710777 | ||||||||
| FaxNumber: | 5183710366 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 OLD PLANK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120653107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183710777 | ||||||||
| FaxNumber: | 5183710366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 1889491 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 1889491 | NY | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1339826 | 05 | NY | MEDICAID | 01339826 | 05 | NY | MEDICAID | 000405090003 | 01 | NY | BSNENY PIN - SPECIALIST | OTHER |