MEDICARE: PHILLIP C. 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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	ME31515	FL

General Provider Information

NPI Number	:	1659353993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP C. GORDON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 144333
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-4333
Country	:	US
Telephone Number	:	407-422-9831
Fax Number	:	407-648-2065

Provider Business Practice Location Address
First Line	:	200 AVENUE F NE
Second Line	:	DEPT. OF PATHOLOGY
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4131
Country	:	US
Telephone Number	:	863-293-1121
Fax Number	:	863-291-6071

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

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	08/03/2007

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