Provider Demographics
NPI:1962896969
Name:CHRISANNE GORDON, MD
Entity type:Organization
Organization Name:CHRISANNE GORDON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-578-2255
Mailing Address - Street 1:6724 PERIMETER LOOP RD.
Mailing Address - Street 2:PMB #317
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 LONDON AVENUE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-578-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042915261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0707328Medicaid
OHGO0462671Medicare UPIN