MEDICARE: DR. BARRY M GORDON M.D.

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	207P00000X	Emergency Medicine Physician	35-04-8104G	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437153368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARRY M GORDON M.D.

Provider Business Mailing Address
First Line	:	411 COMMERCIAL CT STE A
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34292-1650
Country	:	US
Telephone Number	:	941-484-5451
Fax Number	:	941-484-5453

Provider Business Practice Location Address
First Line	:	411 COMMERCIAL CT STE A
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34292-1650
Country	:	US
Telephone Number	:	941-484-5451
Fax Number	:	941-484-5453

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	03/10/2016

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