MEDICARE: LOUELLEN B GURLEY 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	207RG0100X	Gastroenterology Physician	42263	GA

General Provider Information

NPI Number	:	1619918018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOUELLEN B GURLEY M.D.

Provider Business Mailing Address
First Line	:	303 SMITH ST
Second Line	:	CLARK-HOLDER CLINIC, P.A.
City	:	LAGRANGE
State	:	GA
Zip	:	30240-2745
Country	:	US
Telephone Number	:	706-882-8831
Fax Number	:	706-812-4091

Provider Business Practice Location Address
First Line	:	303 SMITH ST
Second Line	:	CLARK-HOLDER CLINIC, P.A.
City	:	LAGRANGE
State	:	GA
Zip	:	30240-2745
Country	:	US
Telephone Number	:	706-882-8831
Fax Number	:	706-812-4091

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	07/08/2007

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