=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053642777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORDON SACK MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2010
-----------------------------------------------------
Last Update Date | 10/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3339 FAIRVIEW ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77504-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-910-6464
-----------------------------------------------------
Fax | 713-910-6995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3339 FAIRVIEW ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77504-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-910-6464
-----------------------------------------------------
Fax | 713-910-6995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GORDON SACK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-910-6464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------