MEDICARE: DR. GORDON B BYRNE D.C.

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	111N00000X	Chiropractor	2576	OH
2	111NS0005X	Sports Physician Chiropractor	2576	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	34-1860598	OTHER	OH	TAX ID
3	2576	OTHER	OH	LICENSE

General Provider Information

NPI Number	:	1114920725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON B BYRNE D.C.

Provider Business Mailing Address
First Line	:	1 PETRO PL STE 2
Second Line	:
City	:	GIRARD
State	:	OH
Zip	:	44420-3123
Country	:	US
Telephone Number	:	330-545-8170
Fax Number	:	330-545-5917

Provider Business Practice Location Address
First Line	:	1 PETRO PL STE 2
Second Line	:
City	:	GIRARD
State	:	OH
Zip	:	44420-3123
Country	:	US
Telephone Number	:	330-545-8170
Fax Number	:	330-545-5917

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	04/25/2024

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