Healthcare Provider Details

I. General information

NPI: 1770104267
Provider Name (Legal Business Name): MICHAEL GORSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W UNIVERSITY BLVD STE 100
DURANT OK
74701-2970
US

IV. Provider business mailing address

2425 W UNIVERSITY BLVD STE 100
DURANT OK
74701-2970
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7331
  • Fax: 580-924-7332
Mailing address:
  • Phone: 580-924-7331
  • Fax: 580-924-7332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: