MEDICARE: DR. GARY E FORD PSYD

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	103G00000X	Clinical Neuropsychologist	4588	OH

General Provider Information

NPI Number	:	1952302358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY E FORD PSYD

Provider Business Mailing Address
First Line	:	2803 TORREY PNES
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45431-8614
Country	:	US
Telephone Number	:	937-408-7711
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 5TH ST
Second Line	:
City	:	WRIGHT PATTERSON AFB
State	:	OH
Zip	:	45433-7951
Country	:	US
Telephone Number	:	937-938-2704
Fax Number	:

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	10/22/2012

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