Provider Demographics
NPI:1598957011
Name:MICHAEL C. GORDON, MD, LLC
Entity Type:Organization
Organization Name:MICHAEL C. GORDON, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-801-0980
Mailing Address - Street 1:4015 S COBB DR SE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6303
Mailing Address - Country:US
Mailing Address - Phone:770-801-0980
Mailing Address - Fax:770-801-9039
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:SUITE 220
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-801-0980
Practice Address - Fax:770-801-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0265342084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA461679OtherBLUE CROSS BLUE SHIELD
GA461679OtherBLUE CROSS BLUE SHIELD
GAB53172Medicare UPIN