MEDICARE: DR. RUSSELL GORE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083A0100X	Aerospace Medicine Physician	052072	GA
2	2084N0400X	Neurology Physician	52072	GA

General Provider Information

NPI Number	:	1003800665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL GORE M.D.

Provider Business Mailing Address
First Line	:	2020 PEACHTREE RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-1426
Country	:	US
Telephone Number	:	404-350-7323
Fax Number	:	404-350-7694

Provider Business Practice Location Address
First Line	:	101 WOODRUFF CIR STE 6000
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-0001
Country	:	US
Telephone Number	:	404-727-5004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	01/31/2018

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