Provider Demographics
NPI:1790903631
Name:JOHN C GORDON MD PA
Entity Type:Organization
Organization Name:JOHN C GORDON MD PA
Other - Org Name:EASTERN SPORTS MEDICINE & ORTHOPAEDIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-574-0077
Mailing Address - Street 1:6830 HOSPITAL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4373
Mailing Address - Country:US
Mailing Address - Phone:301-574-0077
Mailing Address - Fax:301-574-0884
Practice Address - Street 1:6830 HOSPITAL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4373
Practice Address - Country:US
Practice Address - Phone:301-574-0077
Practice Address - Fax:301-574-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD388LMedicare ID - Type Unspecified