Healthcare Provider Details

I. General information

NPI: 1700627080
Provider Name (Legal Business Name): PHILIP NATHAN NORDSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EAST HOSPITAL ROAD
FORT EISENHOWER GA
30905-5650
US

IV. Provider business mailing address

300 E. HOSPITAL ROAD
FORT GORDON GA
30905
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-9358
  • Fax:
Mailing address:
  • Phone: 706-787-9399
  • Fax: 706-787-0304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number114266
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: