Healthcare Provider Details

I. General information

NPI: 1154373157
Provider Name (Legal Business Name): GARY XIN GONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: XIN GARY GONG

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6500
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number056776
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD61497
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: