MEDICARE: DR. GWYN RENE LONDEREE 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	174400000X	Specialist	35-06-9165L	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000197955	OTHER	OH	ANTHEM BC/BS

General Provider Information

NPI Number	:	1225025067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWYN RENE LONDEREE M.D.

Provider Business Mailing Address
First Line	:	1083 FIRTH AVE
Second Line	:
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-2913
Country	:	US
Telephone Number	:	614-442-0100
Fax Number	:	614-442-7753

Provider Business Practice Location Address
First Line	:	4900 GETTYSBURG RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-2520
Country	:	US
Telephone Number	:	614-442-0100
Fax Number	:	614-442-7753

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

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	07/08/2007

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