Provider Demographics
NPI:1346298395
Name:ARCHIBALD, GORDON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:ARCHIBALD
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 1:11995 SINGLETREE LN STE 500
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5349
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1816682085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10045917OtherCDPHP
NY300021945OtherRAIL ROAD MEDICARE
NY01209952Medicaid
NY225139OtherMVP
NY4198679OtherGHI
NYP010181668OtherBCBS
NY040426013873OtherFIDELIS
NY01647929Medicaid
NY181668-5OtherWC
NYE16873Medicare UPIN
NYP010181668OtherBCBS
NY51643HMedicare ID - Type Unspecified
NY01209952Medicaid