Provider Demographics
NPI:1114920725
Name:BYRNE, GORDON B (DC)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:B
Last Name:BYRNE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PETRO PL STE 2
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-3123
Mailing Address - Country:US
Mailing Address - Phone:330-545-8170
Mailing Address - Fax:330-545-5917
Practice Address - Street 1:1 PETRO PL STE 2
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:OH
Practice Address - Zip Code:44420-3123
Practice Address - Country:US
Practice Address - Phone:330-545-8170
Practice Address - Fax:330-545-5917
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2576111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2068393Medicaid
OH34-1860598OtherTAX ID
OH2576OtherLICENSE
OH0840455Medicare ID - Type Unspecified
OH34-1860598OtherTAX ID