MEDICARE: EDWARD S. GORDON DPM PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	EG0000597	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033118658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD S. GORDON DPM PC

Provider Business Mailing Address
First Line	:	25656 SCHOENHERR ROAD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48089-1447
Country	:	US
Telephone Number	:	586-779-4820
Fax Number	:	586-779-9535

Provider Business Practice Location Address
First Line	:	25656 SCHOENHERR ROAD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48089-1447
Country	:	US
Telephone Number	:	586-779-4820
Fax Number	:	586-779-9535

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDWARD SERGE GORDON
Credential	:	DPM
Telephone Number	:	586-779-4820

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	08/22/2020

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