Healthcare Provider Details

I. General information

NPI: 1043288897
Provider Name (Legal Business Name): MICHAEL H GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 N STATE ST
CLARKS SUMMIT PA
18411-1061
US

IV. Provider business mailing address

407 N STATE ST
CLARKS SUMMIT PA
18411-1061
US

V. Phone/Fax

Practice location:
  • Phone: 570-586-1134
  • Fax: 570-586-1136
Mailing address:
  • Phone: 570-586-1134
  • Fax: 570-586-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD059752L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier001596380
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: