Provider Demographics
NPI:1689676843
Name:AIR, GORDON W (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:AIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 SOUTH LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3454
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:560 SOUTH LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3454
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-301-0655
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15743207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000249588OtherANTHEM
KY0428850004OtherMEDICARE DME
KY90008962OtherMEDICAID DME
KY64157431Medicaid
KYCB8861OtherRAILROAD MEDICARE
KY90008962OtherMEDICAID DME
KY64157431Medicaid