Provider Demographics
NPI:1114105665
Name:MAXIE GORDON MD & ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:MAXIE GORDON MD & ASSOCIATES, PLLC
Other - Org Name:GORDON MEDICAL ARTS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TEANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-488-8101
Mailing Address - Street 1:590 SPRINGRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5606
Mailing Address - Country:US
Mailing Address - Phone:601-488-8101
Mailing Address - Fax:662-287-5678
Practice Address - Street 1:590 SPRINGRIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-488-8101
Practice Address - Fax:662-287-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS98012882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08723392Medicaid