MEDICARE: MS. ANGELINA GORDON

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	225100000X	Physical Therapist	029428	NY

General Provider Information

NPI Number	:	1104002526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELINA GORDON

Provider Business Mailing Address
First Line	:	2546 E 13TH ST
Second Line	:	APT. A11
City	:	BROOKLYN
State	:	NY
Zip	:	11235-4358
Country	:	US
Telephone Number	:	718-207-4406
Fax Number	:

Provider Business Practice Location Address
First Line	:	2546 E 13TH ST
Second Line	:	APT A11
City	:	BROOKLYN
State	:	NY
Zip	:	11235-4306
Country	:	US
Telephone Number	:	347-217-6983
Fax Number	:	347-205-7929

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	11/10/2016

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