Healthcare Provider Details

I. General information

NPI: 1508149600
Provider Name (Legal Business Name): BERTHA LYNN GORDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2011
Last Update Date: 09/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 RALPH MCGILL BLVD NE
ATLANTA GA
30308-3339
US

IV. Provider business mailing address

139 RALPH MCGILL BLVD NE
ATLANTA GA
30308-3339
US

V. Phone/Fax

Practice location:
  • Phone: 404-589-9040
  • Fax: 404-589-1615
Mailing address:
  • Phone: 404-589-9040
  • Fax: 404-589-1615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number49018
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: