Healthcare Provider Details

I. General information

NPI: 1114105665
Provider Name (Legal Business Name): MAXIE GORDON MD & ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 SPRINGRIDGE RD
CLINTON MS
39056
US

IV. Provider business mailing address

590 SPRINGRIDGE RD
CLINTON MS
39056-5606
US

V. Phone/Fax

Practice location:
  • Phone: 601-488-8101
  • Fax: 662-287-5678
Mailing address:
  • Phone: 601-488-8101
  • Fax: 662-287-5678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9801288
License Number StateMS

VIII. Authorized Official

Name: TEANDRA WALTON
Title or Position: DIRECTOR OF BUSINESS OPERATIONS
Credential:
Phone: 601-488-8101