Provider Demographics
NPI:1568496677
Name:GORDON, PAUL C (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:117 ELLENFIELD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:208 COLLYER ST
Practice Address - Street 2:STE 100
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-793-7191
Practice Address - Fax:401-793-7200
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-03-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RIMD8392207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006737Medicaid
RIA2168303Medicare Oscar/Certification
E57591Medicare UPIN
RIA2168302Medicare Oscar/Certification
RI9006737Medicaid
RIU400119653Medicare Oscar/Certification