MEDICARE: DR. GARY LOWELL WHITACRE 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	207QA0505X	Adult Medicine Physician	35025958	OH

General Provider Information

NPI Number	:	1831418177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LOWELL WHITACRE M.D.

Provider Business Mailing Address
First Line	:	768 BERING CT
Second Line	:
City	:	WESTERVILLE
State	:	OH
Zip	:	43081-6203
Country	:	US
Telephone Number	:	614-890-1755
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 SCARBOROUGH BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4730
Country	:	US
Telephone Number	:	614-863-7116
Fax Number	:

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

Provider Enumeration Date	:	05/26/2010
Last Update Date	:	05/26/2010

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