Basic Information
| Provider Information | |||||||||
| NPI: | 1306813274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 NEWBURYPORT RD | ||||||||
| Address2: | |||||||||
| City: | UPPER HOLLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190531556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158604110 | ||||||||
| FaxNumber: | 2672958208 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD054695L | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MA62314 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 7205007 | 05 | NJ | MEDICAID |