Healthcare Provider Details

I. General information

NPI: 1144394362
Provider Name (Legal Business Name): GAINESVILLE OTOLARYNGOLOGY GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 NW 11 PL
GAINESVILLE FL
32605
US

IV. Provider business mailing address

6821 NW 11 PL
GAINESVILLE FL
32605
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-6700
  • Fax: 352-332-0890
Mailing address:
  • Phone: 352-331-6700
  • Fax: 352-332-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberFLME0038170
License Number StateFL

VIII. Authorized Official

Name: JAMES A GERSHOW
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 352-331-6700