Provider Demographics
| NPI: | 1063771798 |
|---|---|
| Name: | GORDIAN MEDICAL II, INC. |
| Entity type: | Organization |
| Organization Name: | GORDIAN MEDICAL II, INC. |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JEFFREY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BOWMAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 714-566-0200 |
| Mailing Address - Street 1: | 750 THE CITY DR S STE 225 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | ORANGE |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 92868-4976 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 714-566-0200 |
| Mailing Address - Fax: | 877-380-8282 |
| Practice Address - Street 1: | 5834 LOUETTA RD |
| Practice Address - Street 2: | SUITE D |
| Practice Address - City: | SPRING |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 77379-7884 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 281-205-7091 |
| Practice Address - Fax: | 281-205-7093 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | GORDIAN MEDICAL, INC. |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2012-05-15 |
| Last Update Date: | 2024-03-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| TX | 28042 | 332B00000X, 3336C0003X |
| 333600000X, 3336L0003X, 3336C0004X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
| Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | |
| No | 333600000X | Suppliers | Pharmacy | |
| No | 3336L0003X | Suppliers | Pharmacy | Long Term Care Pharmacy |
| No | 3336C0004X | Suppliers | Pharmacy | Compounding Pharmacy |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NE | 10026638400 | Medicaid | |
| IL | 1063771798 | Medicaid | |
| IL | 203002585 | Other | DME LICENSE |
| NH | 3125558 | Medicaid | |
| CO | 9000143125 | Medicaid | |
| AZ | 103822 | Medicaid | |
| MN | 1063771798 | Medicaid | |
| CT | 1063771798 | Medicaid | |
| NC | 1063771798 | Medicaid | |
| WA | 2149270 | Medicaid | |
| NM | 58080708 | Medicaid | |
| LA | DME000833 | Other | DME LICENSE |
| NH | 08547 | Other | DME LICENSE |
| MS | 09722542 | Medicaid | |
| WI | 1063771798 | Medicaid | |
| AK | 1703530 | Medicaid | |
| IN | 300003799 | Medicaid | |
| VT | 6709192 | Medicaid | |
| IN | 69001683A | Other | DME LICENSE |
| TN | Q030405 | Medicaid | |
| GA | 003250708A | Medicaid | |
| OH | 0234809 | Medicaid | |
| NJ | 0792748 | Medicaid | |
| MS | 09722542 | Other | DME LICENSE |
| PA | 1032341780002 | Medicaid | |
| ID | 1063771798 | Medicaid | |
| VA | 1063771798 | Medicaid | |
| IA | 1063771798 | Medicaid | |
| CA | 1063771798 | Medicaid | |
| OR | 1063771798 | Medicaid | |
| KS | 201149250B | Medicaid | |
| AL | 245633 | Medicaid | |
| LA | 2566415 | Medicaid | |
| MD | 424436200 | Medicaid | |
| CT | CSW.0004625 | Other | DME LICENSE |
| KY | 7100477670 | Medicaid | |
| HI | DME0265 | Other | DME LICENSE |
| MI | 1063771798 | Medicaid | |
| MT | 1063771798 | Medicaid | |
| CA | 112099 | Other | DME LICENSE |
| SC | 1648 | Medicaid | |
| KY | 265664 | Other | DME LICENSE |
| AR | 2745657411 | Medicaid | |
| TX | 426324601 | Medicaid | |
| OK | 200699500A | Medicaid | |
| UT | 3001875 | Medicaid | |
| MI | 5306006349 | Other | DME LICENSE |
| AZ | C001980 | Other | DME LICENSE |
| GA | PHDME000700 | Other | DME LICENSE |
