MEDICARE: THE GORDON INSTITUTE FOR HUMAN PERFORMANCE LLC

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	17059	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1457358772	OTHER	MD	NPI

General Provider Information

NPI Number	:	1659519122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GORDON INSTITUTE FOR HUMAN PERFORMANCE LLC

Provider Business Mailing Address
First Line	:	3655A OLD COURT RD
Second Line	:	STE 16
City	:	PIKESVILLE
State	:	MD
Zip	:	21208-3959
Country	:	US
Telephone Number	:	410-977-9416
Fax Number	:

Provider Business Practice Location Address
First Line	:	3655A OLD COURT RD
Second Line	:	STE 16
City	:	PIKESVILLE
State	:	MD
Zip	:	21208-3959
Country	:	US
Telephone Number	:	410-977-9416
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ERIC MILES GORDON
Credential	:	PT
Telephone Number	:	410-977-9416

Provider Enumeration Date	:	01/21/2009
Last Update Date	:	08/04/2009

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