=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285647115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEOFFREY J. GORSE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 01/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1225 S GRAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-577-8000
-----------------------------------------------------
Fax | 314-977-9196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 S GRAND BLVD DRC-8
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-1015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-977-5500
-----------------------------------------------------
Fax | 314-771-3816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | G37510
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | R4J28
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------