=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184620270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN SCHULZ GORDON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 10/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 856 W 4TH NORTH ST
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-587-0067
-----------------------------------------------------
Fax | 423-581-5882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 856 W 4TH NORTH ST
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-587-0067
-----------------------------------------------------
Fax | 423-581-5882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 019858
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------