Provider Demographics
NPI:1235240516
Name:GORDON, MICHAEL NOLAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NOLAN
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 1:751 DERBY DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:AL
Mailing Address - Zip Code:36925-2121
Mailing Address - Country:US
Mailing Address - Phone:205-392-5263
Mailing Address - Fax:
Practice Address - Street 1:751 DERBY DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:AL
Practice Address - Zip Code:36925-2121
Practice Address - Country:US
Practice Address - Phone:205-392-5263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22660282N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552669Medicaid
AL051552669Medicare ID - Type Unspecified
AL051552669Medicaid