Provider Demographics
NPI:1205913092
Name:FALLON T GORDON MD PA
Entity type:Organization
Organization Name:FALLON T GORDON MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FALLON
Authorized Official - Middle Name:TURLEY
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:409-835-0761
Mailing Address - Street 1:5060 LITTLEWOOD DRIVE
Mailing Address - Street 2:FALLON T GORDON MD
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706
Mailing Address - Country:US
Mailing Address - Phone:409-892-5992
Mailing Address - Fax:409-892-4834
Practice Address - Street 1:810 HOSPITAL DRIVE
Practice Address - Street 2:#370
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4657
Practice Address - Country:US
Practice Address - Phone:409-835-0761
Practice Address - Fax:409-892-4834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J24QMedicare PIN
TXB87909Medicare UPIN