Basic Information
| Provider Information | |||||||||
| NPI: | 1982652939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 W 69TH ST | ||||||||
| Address2: | NORTH CENTRAL HEART INSTITUTE | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 3929 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 331503700 | 05 | MN | MEDICAID | 10492 | 01 | HEALTHPARTNERS | OTHER | 165025 | 01 | MN | UCARE | OTHER | 25-00667 | 01 | MEDICA SELECTCARE | OTHER | 33333 | 01 | IA | IA BCBS # | OTHER | 6002892 | 05 | SD | MEDICAID | 931451030123 | 01 | PREFERRED ONE | OTHER | 0549402 | 05 | IA | MEDICAID | 101T6GO | 01 | MN | MN BCBS - PLAN 91057NO | OTHER | 346L9GO | 01 | MN | MN BCBS - PLAN 538R2NO | OTHER | 3929 | 01 | SD | DAKOTACARE | OTHER | 0008426 | 01 | SD | SD BCBS | OTHER |