Healthcare Provider Details

I. General information

NPI: 1518935121
Provider Name (Legal Business Name): ROBERT ROLAND GORMAN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/27/2023
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST SUITE M401
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

601 JOHN ST SUITE M401
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 855-618-2676
  • Fax: 269-488-3241
Mailing address:
  • Phone: 855-618-2676
  • Fax: 269-488-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301072238
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2004-0315
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number4301072238
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: