Provider Demographics
NPI:1427084755
Name:GORDON FAMILY MEDICINE
Entity type:Organization
Organization Name:GORDON FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ANTHONY NUTTALL
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-272-0444
Mailing Address - Street 1:725 OAKRIDGE BLVD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2351
Mailing Address - Country:US
Mailing Address - Phone:910-272-0444
Mailing Address - Fax:910-272-0445
Practice Address - Street 1:725 OAKRIDGE BLVD
Practice Address - Street 2:SUITE A-1
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2351
Practice Address - Country:US
Practice Address - Phone:910-272-0444
Practice Address - Fax:910-272-0445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901642261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903383Medicaid
NC5903383Medicaid