1306117668 NPI number — STEVEN P GORMAN MD INC.

Table of content: (NPI 1306117668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306117668 NPI number — STEVEN P GORMAN MD INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN P GORMAN MD INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STEVEN P GORMAN MD
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306117668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78150 CALLE TAMPICO
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LA QUINTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92253-2907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-564-1886
Provider Business Mailing Address Fax Number:
760-564-8558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78150 CALLE TAMPICO
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-564-1886
Provider Business Practice Location Address Fax Number:
760-564-8558
Provider Enumeration Date:
01/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GORMAN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-564-7886

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G83973 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G839730 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104926500 . This is a "INDV. NPI#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FY520Z . This is a "MCR PTAN IND" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FY791A . This is a "MCR PTAN GRP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1306117668 . This is a "MCR NPI GRP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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