Provider Demographics
NPI:1235494550
Name:GORDON & MANGAN TRAVELERS CLINIC, LLC
Entity Type:Organization
Organization Name:GORDON & MANGAN TRAVELERS CLINIC, LLC
Other - Org Name:PASSPORT HEALTH NORTHERN OHIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER, EXECUTIVE DIRECTOR & CLIN
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:KILBANE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:216-295-9400
Mailing Address - Street 1:21825 CHAGRIN BLVD.
Mailing Address - Street 2:SUITE 345
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5352
Mailing Address - Country:US
Mailing Address - Phone:216-295-9400
Mailing Address - Fax:216-283-8120
Practice Address - Street 1:21825 CHAGRIN BLVD.
Practice Address - Street 2:SUITE 345
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5352
Practice Address - Country:US
Practice Address - Phone:216-295-9400
Practice Address - Fax:216-283-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN140601163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty