Healthcare Provider Details

I. General information

NPI: 1902277528
Provider Name (Legal Business Name): KEVIN GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE.
CLEVELAND OH
44106
US

IV. Provider business mailing address

11500 SOMERSET DR APT 121
NORTH ROYALTON OH
44133-2670
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-4057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number325850
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: