MEDICARE: JEFFREY RYAN GOURLEY 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	2085R0202X	Diagnostic Radiology Physician	0101245462	VA
2	2085R0204X	Vascular & Interventional Radiology Physician	0101245462	VA

General Provider Information

NPI Number	:	1194969204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY RYAN GOURLEY M.D.

Provider Business Mailing Address
First Line	:	110 KINGSLEY LN STE 305
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23505-4617
Country	:	US
Telephone Number	:	757-889-5422
Fax Number	:	757-889-5450

Provider Business Practice Location Address
First Line	:	110 KINGLEY LANE
Second Line	:	SUITE 305
City	:	NORFOLK
State	:	VA
Zip	:	23505-4617
Country	:	US
Telephone Number	:	757-889-5942
Fax Number	:	757-889-5450

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

Provider Enumeration Date	:	04/21/2009
Last Update Date	:	06/18/2019

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