MEDICARE: DR. GORDON BRUCE HEALEY M.D.

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	208800000X	Urology Physician	E2602	TX

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

General Provider Information

NPI Number	:	1164427662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON BRUCE HEALEY M.D.

Provider Business Mailing Address
First Line	:	3180 CENTRAL MALL DR
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-8039
Country	:	US
Telephone Number	:	409-729-6231
Fax Number	:	409-727-6537

Provider Business Practice Location Address
First Line	:	3180 CENTRAL MALL DR
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-8039
Country	:	US
Telephone Number	:	409-729-6231
Fax Number	:	409-727-6537

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	01/11/2011

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