Basic Information
| Provider Information | |||||||||
| NPI: | 1932191582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 PINE ST | ||||||||
| Address2: | STE 760 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336090 | ||||||||
| FaxNumber: | 4786334080 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 PINE ST | ||||||||
| Address2: | STE 760 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336090 | ||||||||
| FaxNumber: | 4786334080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2006 | ||||||||
| NPIReactivationDate: | 04/10/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 066740 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 278322300 | 05 | FL | MEDICAID | 778269 | 05 | AZ | MEDICAID |