Healthcare Provider Details

I. General information

NPI: 1174515522
Provider Name (Legal Business Name): BYRON BLAKE GORMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 WORNALL RD
KANSAS CITY MO
64111
US

IV. Provider business mailing address

901 E 104TH STREET MAILSTOP 400S
KANSAS CITY MO
64131
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-3679
  • Fax: 816-932-9089
Mailing address:
  • Phone: 816-502-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number05-42050
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number0542050
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number2019009913
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: