NPIMap

Individual provider Active NPI

Jefferson Taylor Gordon, M.D.

  • Family Medicine Physician
  • Carrollton, GA
National Provider Identifier
1336167816
Registry record updated Jan 4, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
033338 Issued in GA
Practice address
100 Professional PL
Suite 202
Carrollton, GA 30117-3802
Phone
(770) 832-6861
Fax
(770) 832-9432
NPI assigned
Jul 17, 2006
Last updated
Jan 4, 2012By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 4, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 033338 GA Primary

Addresses

Primary practice location

100 Professional PL
Suite 202
Carrollton, GA 30117-3802

Mailing address

100 Professional PL
Suite 202
Carrollton, GA 30117-3802
Phone (770) 832-6861

Other identifiers 1

IdentifierTypeStateIssuer
000460996CMedicaidGA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20081114000696 GA Practitioner - Family Practice 3274587399 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 1989
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

100 Professional PL
Suite 202
Carrollton, GA 30117-3802
Phone (770) 832-6861

101 Yorktown Dr
Fayetteville, GA 30214-1578

101 Yorktown Dr
Suite 100
Fayetteville, GA 30214-7663
Phone (770) 460-4285

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
033338GAMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Privia Medical Group of Georgia LLC Family Medicine CurrentSince Apr 28, 2020 Accepting new patients
Privia Medical Group of Georgia LLC Family Medicine CurrentSince Apr 28, 2020 Accepting new patients
Privia Medical Group, LLC Family Medicine Past Accepting new patients

Locations

101 Yorktown Dr
Ste 100
Fayetteville, GA 30214
Phone (770) 460-4285

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/8042/brand/1/csg/1/fhir/r4
  • Direct secure messaging: jefferson.gordon.1@8042.direct.athenahealth.com
  • Direct secure messaging: tgordon@ppms.gwaydirect.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153094400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1325635200000",
    "number": "1336167816",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 PROFESSIONAL PL",
            "address_2": "SUITE 202",
            "city": "CARROLLTON",
            "state": "GA",
            "postal_code": "301173802",
            "telephone_number": "770-832-6861",
            "fax_number": "770-832-9432"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 PROFESSIONAL PL",
            "address_2": "SUITE 202",
            "city": "CARROLLTON",
            "state": "GA",
            "postal_code": "301173802",
            "telephone_number": "770-832-6861",
            "fax_number": "770-832-9432"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GORDON",
        "first_name": "JEFFERSON",
        "middle_name": "TAYLOR",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-17",
        "last_updated": "2012-01-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "033338",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000460996C",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Carrollton, GA

Sources for this page

Verify at the official NPI Registry.