Healthcare Provider Details

I. General information

NPI: 1740274729
Provider Name (Legal Business Name): JOHN MICHAEL GORLOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 03/30/2006

III. Provider practice location address

761 JOHNSONBURG RD SUITE 360
ST MARYS PA
15857-3483
US

IV. Provider business mailing address

761 JOHNSONBURG RD SUITE 360
ST MARYS PA
15857-3483
US

V. Phone/Fax

Practice location:
  • Phone: 814-781-8677
  • Fax: 814-781-8246
Mailing address:
  • Phone: 814-781-8677
  • Fax: 814-781-8246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number024093
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD056208-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: