Healthcare Provider Details

I. General information

NPI: 1285893891
Provider Name (Legal Business Name): KELLY S GORMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY S SWEENEY

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 MCINTOSH CIR STE 1
JOPLIN MO
64804-3614
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-8750
  • Fax: 417-347-8788
Mailing address:
  • Phone: 417-347-3649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTRN8725
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014008958
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: