Provider Demographics
NPI:1194761924
Name:GORDON, ANDREW JOHN (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOHN
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST STE M-283
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5382
Mailing Address - Country:US
Mailing Address - Phone:269-349-7696
Mailing Address - Fax:269-349-0610
Practice Address - Street 1:601 JOHN ST STE M-283
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5382
Practice Address - Country:US
Practice Address - Phone:269-349-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG067751174400000X
MI4301067751208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020A312720OtherBCBSM GROUP ID
MI4848964Medicaid
MI4227783Medicaid
MION91940Medicare ID - Type UnspecifiedTHIS IS GROUP MEDICARE ID
MI0A37669Medicare PIN
MI0M9860003Medicare UPIN
MI4227783Medicaid
MI020A312720OtherBCBSM GROUP ID