Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | 026534 | GA |
NPI | 1184608077 |
---|---|
Provider Name | Dr. Michael Cowl Gordon |
First Address | Atlanta, GA 30339-2061 |
Second Address | Atlanta, GA 30339-2061 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2005 |
Last Update Date | 18/06/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000290463A | (05) | GA |
461670 | BLUE CROSS BLUE SHIELD (01) | GA |
B53172 | (02) | GA |