MEDICARE: GORDON HEART CLINIC 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	174400000X	Specialist

General Provider Information

NPI Number	:	1225019334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORDON HEART CLINIC PC

Provider Business Mailing Address
First Line	:	5200 PARK AVE
Second Line	:	SUITE 102
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3500
Country	:	US
Telephone Number	:	901-333-0330
Fax Number	:	901-333-0337

Provider Business Practice Location Address
First Line	:	5200 PARK AVE
Second Line	:	SUITE 102
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3500
Country	:	US
Telephone Number	:	901-333-0330
Fax Number	:	901-333-0337

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. ANGELA GORDON
Credential	:
Telephone Number	:	901-333-0330

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	04/29/2008

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