Healthcare Provider Details

I. General information

NPI: 1265134910
Provider Name (Legal Business Name): ERIC ANTHONY GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7068 S OUTER 364
O FALLON MO
63368-7757
US

IV. Provider business mailing address

18 OAKWOOD DR
SAINT CHARLES MO
63301-1325
US

V. Phone/Fax

Practice location:
  • Phone: 636-240-6100
  • Fax:
Mailing address:
  • Phone: 636-577-1047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: