Healthcare Provider Details

I. General information

NPI: 1346246220
Provider Name (Legal Business Name): GORDON E MELVILLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 PARK AVE STE 107
EDISON NJ
08820-3032
US

IV. Provider business mailing address

579A CRANBURY RD
EAST BRUNSWICK NJ
08816-5426
US

V. Phone/Fax

Practice location:
  • Phone: 732-548-6800
  • Fax: 732-548-6290
Mailing address:
  • Phone: 732-390-0040
  • Fax: 732-390-1856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA04658000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5144302
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier300102255
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerRAILROAD MEDICARE - WARREN
# 3
Identifier300009505
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerRAILROAD MEDICARE - EDISON
# 4
Identifier300025888
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerRAILROAD MEDICARE - BRIDGEWATER
# 5
Identifier300102255
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerRAILROAD MEDICARE - SMC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: