Provider Demographics
NPI:1982694014
Name:GORDON, BRIAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-2014
Mailing Address - Country:US
Mailing Address - Phone:518-382-7200
Mailing Address - Fax:518-382-7205
Practice Address - Street 1:530 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2014
Practice Address - Country:US
Practice Address - Phone:518-382-7200
Practice Address - Fax:518-382-7205
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209643207X00000X, 207XS0114X, 207XS0117X, 207XX0004X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Not Answered207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Not Answered207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Not Answered207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01935579Medicaid
BB6652Medicare ID - Type Unspecified
BB6655Medicare ID - Type UnspecifiedCPK
56357AMedicare ID - Type UnspecifiedCLIFTON PARK -GROUP
56356AMedicare ID - Type UnspecifiedGROUP
NY01935579Medicaid