Healthcare Provider Details

I. General information

NPI: 1891765418
Provider Name (Legal Business Name): MARK JEFFREY GORMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 SPRING ST
SCARBOROUGH ME
04074-8926
US

IV. Provider business mailing address

300 SOUTHBOROUGH DR SUITE 201
SOUTH PORTLAND ME
04106-6914
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-1414
  • Fax:
Mailing address:
  • Phone: 207-661-2000
  • Fax: 207-661-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD21232
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberMD21232
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: