Provider Demographics
NPI:1962456103
Name:GORDON MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:GORDON MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:K
Authorized Official - Last Name:IJELU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-924-2244
Mailing Address - Street 1:121 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1295
Mailing Address - Country:US
Mailing Address - Phone:215-924-2244
Mailing Address - Fax:215-924-2228
Practice Address - Street 1:6329 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-2009
Practice Address - Country:US
Practice Address - Phone:215-924-2244
Practice Address - Fax:215-924-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044243E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1243184Medicaid
PAE84242Medicare UPIN
PA232352Medicare PIN