Provider Demographics
NPI:1497953822
Name:GORDONIA EMERGENCY PHYSICIANS
Entity Type:Organization
Organization Name:GORDONIA EMERGENCY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVASNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-355-0808
Mailing Address - Street 1:PO BOX 41631
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-1631
Mailing Address - Country:US
Mailing Address - Phone:800-355-0808
Mailing Address - Fax:215-834-2862
Practice Address - Street 1:247 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4605
Practice Address - Country:US
Practice Address - Phone:912-557-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty