MEDICARE: MARY GWEN GORMAN 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	207P00000X	Emergency Medicine Physician	H3249	TX

General Provider Information

NPI Number	:	1710925359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY GWEN GORMAN M.D.

Provider Business Mailing Address
First Line	:	2228 BAUGH RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78754-4115
Country	:	US
Telephone Number	:	512-323-2795
Fax Number	:

Provider Business Practice Location Address
First Line	:	821 N BROADWAY ST
Second Line	:
City	:	ASPERMONT
State	:	TX
Zip	:	79502-2029
Country	:	US
Telephone Number	:	940-988-4366
Fax Number	:

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

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	03/02/2023

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