Provider Demographics
NPI:1801053111
Name:DR. MANUEL E. GORDILLO INC.
Entity type:Organization
Organization Name:DR. MANUEL E. GORDILLO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GORDILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-835-6189
Mailing Address - Street 1:30400 DETROIT RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1872
Mailing Address - Country:US
Mailing Address - Phone:440-835-6189
Mailing Address - Fax:440-899-4357
Practice Address - Street 1:30400 DETROIT RD
Practice Address - Street 2:SUITE 304
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1872
Practice Address - Country:US
Practice Address - Phone:440-835-6189
Practice Address - Fax:440-899-4357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH028854261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000126508OtherANTHEM ID
OH0123780Medicaid
OHGO0141272Medicare UPIN
000000126508OtherANTHEM ID