Provider Demographics
NPI:1215020755
Name:GORDON, CARRIE A (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-621-2000
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:887 CONGRESS ST.
Practice Address - Street 2:SUITE 320
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-5522
Practice Address - Fax:207-662-5527
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-04-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MEMD16227208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204313Medicaid
ME407810099Medicaid
MEME0702Medicare PIN
MEME070202Medicare PIN
NH30204313Medicaid
MEME070201Medicare PIN
MEI09853Medicare UPIN