MEDICARE: LAUREN KANTOR GORMAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	134719	NY

General Provider Information

NPI Number	:	1053311340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN KANTOR GORMAN MD

Provider Business Mailing Address
First Line	:	685 W END AVE
Second Line	:	SUITE 1AF
City	:	NEW YORK
State	:	NY
Zip	:	10025-6819
Country	:	US
Telephone Number	:	212-580-7713
Fax Number	:	718-548-0568

Provider Business Practice Location Address
First Line	:	685 W END AVE
Second Line	:	SUITE A1F
City	:	NEW YORK
State	:	NY
Zip	:	10025-6819
Country	:	US
Telephone Number	:	212-580-7713
Fax Number	:	718-548-0568

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/08/2007

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