=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871599407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDEN THOMAS MCMURRY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 04/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4004 DUPONT CIR SUITE 220
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-893-0159
-----------------------------------------------------
Fax | 502-213-3853
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 950116 SUITE 220
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40295-0116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-893-0159
-----------------------------------------------------
Fax | 502-213-3853
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 14174
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 14174
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 01039324A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207YX0901X
-----------------------------------------------------
Taxonomy Name | Otology & Neurotology Physician
-----------------------------------------------------
License Number | 14174
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------