MEDICARE: DR. ELIZABETH GORDON M.D.

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	207Q00000X	Family Medicine Physician	060177	GA

General Provider Information

NPI Number	:	1548445356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH GORDON M.D.

Provider Business Mailing Address
First Line	:	2107 N DECATUR RD
Second Line	:	#434
City	:	DECATUR
State	:	GA
Zip	:	30033-5305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 BLUEBIRD BLVD
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-5082
Country	:	US
Telephone Number	:	478-825-8691
Fax Number	:

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

Provider Enumeration Date	:	12/31/2007
Last Update Date	:	02/20/2010

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