Basic Information
| Provider Information | |||||||||
| NPI: | 1780678433 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | H.W. GORDON, M.D., MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 HOSPITAL DR | ||||||||
| Address2: | DEPT OF PATHOLOGY | ||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954824531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074623111 | ||||||||
| FaxNumber: | 7074637509 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 HOSPITAL DR | ||||||||
| Address2: | DEPT OF PATHOLOGY | ||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954824531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074623111 | ||||||||
| FaxNumber: | 7074637509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | HERSCHEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7074623111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00C207190 | 05 | CA | MEDICAID | 00C207191 | 05 | CA | MEDICAID |