Healthcare Provider Details

I. General information

NPI: 1790718930
Provider Name (Legal Business Name): MICHAEL J GORMAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 NORTH OUTER FORTY SUITE 205
CHESTERFIELD MO
63005-1361
US

IV. Provider business mailing address

17300 NORTH OUTER FORTY RD SUITE 205
CHESTERFIELD MO
63005-1361
US

V. Phone/Fax

Practice location:
  • Phone: 636-728-1777
  • Fax: 636-728-1793
Mailing address:
  • Phone: 636-728-1777
  • Fax: 636-728-1793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number103326
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: