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NPI Code Detail

MEDICARE: SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC

MEDICARE: SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207VE0102XReproductive Endocrinology Physician

General Provider Information

NPI Number : 1043852601
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC
Provider Business Mailing Address
First Line : PO BOX 25686
Second Line :
City : BELFAST
State : ME
Zip : 04915-2007
Country : US
Telephone Number : 617-402-1000
Fax Number : 617-402-1099
Provider Business Practice Location Address
First Line : 11126 KINGSTON PIKE
Second Line :
City : KNOXVILLE
State : TN
Zip : 37934-2806
Country : US
Telephone Number : 865-777-0088
Fax Number : 865-777-2015
Authorized Official
Title or Position : OWNER
Name : JOHN D. GORDON
Credential : MD
Telephone Number : 865-777-0088
Provider Enumeration Date : 10/15/2019
Last Update Date : 10/15/2019

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Directions to “SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC ” Practice Location

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