MEDICARE: MR. MATTHEW C GORDON L.A.T., A.T.C.

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
1	2255A2300X	Athletic Trainer	AT3026	TX

General Provider Information

NPI Number	:	1306812342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW C GORDON L.A.T., A.T.C.

Provider Business Mailing Address
First Line	:	5603 JANE AUSTEN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5603 JANE AUSTEN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1959
Country	:	US
Telephone Number	:	214-893-6223
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	07/08/2007

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