MEDICARE: GORDON SHERMAN PARK MD

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	207V00000X	Obstetrics & Gynecology Physician	114124-1205	UT

General Provider Information

NPI Number	:	1881784403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON SHERMAN PARK MD

Provider Business Mailing Address
First Line	:	PO BOX 510708
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84151-0708
Country	:	US
Telephone Number	:	801-213-9200
Fax Number	:	801-213-9202

Provider Business Practice Location Address
First Line	:	3730 W 4700 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-3457
Country	:	US
Telephone Number	:	801-213-9200
Fax Number	:	801-213-9202

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	01/30/2014

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