Provider Demographics
NPI:1982717955
Name:CHARLES R GORDON MD PA
Entity Type:Organization
Organization Name:CHARLES R GORDON MD PA
Other - Org Name:PRECISION SPINE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-592-6000
Mailing Address - Street 1:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6605
Mailing Address - Country:US
Mailing Address - Phone:903-592-6000
Mailing Address - Fax:903-595-1592
Practice Address - Street 1:2737 S BROADWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5445
Practice Address - Country:US
Practice Address - Phone:903-592-6000
Practice Address - Fax:903-595-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163108701Medicaid
0023KVOtherBLUE CROSS BLUE SHIELD
TX00805VMedicare PIN
TX6384180001Medicare NSC