Provider Demographics
NPI:1053642777
Name:GORDON SACK MD PA
Entity Type:Organization
Organization Name:GORDON SACK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-910-6464
Mailing Address - Street 1:3339 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-1903
Mailing Address - Country:US
Mailing Address - Phone:713-910-6464
Mailing Address - Fax:713-910-6995
Practice Address - Street 1:3339 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1903
Practice Address - Country:US
Practice Address - Phone:713-910-6464
Practice Address - Fax:713-910-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC21456Medicare UPIN
TX0A6011Medicare PIN