Healthcare Provider Details

I. General information

NPI: 1972576775
Provider Name (Legal Business Name): MARY JO GORMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DRIVE
BRIDGETON MO
63044-5536
US

IV. Provider business mailing address

999 EXECUTIVE PARKWAY DR SUITE 320
SAINT LOUIS MO
63141-6336
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax: 314-514-6020
Mailing address:
  • Phone: 314-514-6000
  • Fax: 314-514-6020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberR5G50
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: