Provider Demographics
NPI:1265202121
Name:MCMICHAEL, GORDON F III (HM1, USN)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:F
Last Name:MCMICHAEL
Suffix:III
Gender:M
Credentials:HM1, USN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 OSPREY DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3150
Mailing Address - Country:US
Mailing Address - Phone:814-923-7721
Mailing Address - Fax:
Practice Address - Street 1:75 OSPREY DR
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3150
Practice Address - Country:US
Practice Address - Phone:814-923-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman