MEDICARE: PAUL T. GUSTAFSON D.O.

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	208600000X	Surgery Physician	TL#656	WY
2	208600000X	Surgery Physician	2894	IA
3	208600000X	Surgery Physician	5101015864	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	314100	OTHER	WY	BCBS

General Provider Information

NPI Number	:	1528033644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL T. GUSTAFSON D.O.

Provider Business Mailing Address
First Line	:	7100 COMMERCE WAY
Second Line	:	SUITE 180
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-2829
Country	:	US
Telephone Number	:	615-465-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	196 ARROWHEAD DR
Second Line	:	STE 9
City	:	EVANSTON
State	:	WY
Zip	:	82930-8752
Country	:	US
Telephone Number	:	307-783-8280
Fax Number	:

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

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	04/11/2008

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