Provider Demographics
NPI:1053458653
Name:GORDON, TERRY R (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:22777 W. ELEVEN MILE RD
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:248-358-0722
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:22777 W. ELEVEN MILE RD
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034
Practice Address - Country:US
Practice Address - Phone:248-358-0722
Practice Address - Fax:248-358-8658
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TG048641OtherCHAMPUS-CHAMPUS
TG048641OtherCOMMERCIAL-COMMERCIAL NUMBER
TG048641OtherCHAMPUS-CHAMPUS