MEDICARE: MARYELLEN GORDIAN MD

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	208D00000X	General Practice Physician	2758	AK

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	:	1194704619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYELLEN GORDIAN MD

Provider Business Mailing Address
First Line	:	PO BOX 241769
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99524-1769
Country	:	US
Telephone Number	:	907-770-2380
Fax Number	:	907-770-2390

Provider Business Practice Location Address
First Line	:	BLDG 60702
Second Line	:
City	:	FT RICHARDSON
State	:	AK
Zip	:	99505
Country	:	US
Telephone Number	:	907-384-6017
Fax Number	:

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

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	07/08/2007

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