MEDICARE: DR. PATRICK MICHAEL GORMAN D.D.S.

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	1223G0001X	General Practice Dentistry	19A14567	IL

General Provider Information

NPI Number	:	1093011132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICK MICHAEL GORMAN D.D.S.

Provider Business Mailing Address
First Line	:	615 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2329
Country	:	US
Telephone Number	:	708-331-1900
Fax Number	:	708-331-1248

Provider Business Practice Location Address
First Line	:	615 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2329
Country	:	US
Telephone Number	:	708-331-1900
Fax Number	:	708-331-1248

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

Provider Enumeration Date	:	02/08/2011
Last Update Date	:	02/08/2011

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