MEDICARE: DR. HERMAN CLARK 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	174400000X	Specialist	9900850	NC
2	208100000X	Physical Medicine & Rehabilitation Physician	9900850	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1225X	OTHER	NC	BLUE CROSS BLUE SHEILD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336103365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HERMAN CLARK GORE M.D.

Provider Business Mailing Address
First Line	:	900 COX RD
Second Line	:	SUITE A
City	:	GASTONIA
State	:	NC
Zip	:	28054-3460
Country	:	US
Telephone Number	:	704-864-3300
Fax Number	:	704-864-3300

Provider Business Practice Location Address
First Line	:	900 COX RD
Second Line	:	SUITE A
City	:	GASTONIA
State	:	NC
Zip	:	28054-3460
Country	:	US
Telephone Number	:	704-864-3300
Fax Number	:	704-864-2002

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	12/07/2022

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