Provider Demographics
NPI:1417991225
Name:GORDON, ROBERT (MED)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-6340
Mailing Address - Fax:717-851-6349
Practice Address - Street 1:3550 CONCORD RD
Practice Address - Street 2:SUITE 4
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8626
Practice Address - Country:US
Practice Address - Phone:717-851-6340
Practice Address - Fax:717-851-6349
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002355L103T00000X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2176815OtherCIGNA BEHAVIORAL HEALTH
PA01097501OtherCAPITAL BLUE CROSS
PA119323OtherVALUE OPTIONS
PA279849000OtherMAGELLAN
PAGO154450OtherPA BLUE SHIELD
PA2176815OtherCIGNA BEHAVIORAL HEALTH
PA166102Medicare ID - Type Unspecified