Healthcare Provider Details

I. General information

NPI: 1184608077
Provider Name (Legal Business Name): MICHAEL COWL GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2005
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WATER PL SE SUITE 100
ATLANTA GA
30339-2061
US

IV. Provider business mailing address

1800 WATER PL SE SUITE 100
ATLANTA GA
30339-2061
US

V. Phone/Fax

Practice location:
  • Phone: 770-801-0980
  • Fax: 770-801-9039
Mailing address:
  • Phone: 770-801-0980
  • Fax: 770-801-9039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number026534
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: