Provider Demographics
NPI:1285647115
Name:GORSE, GEOFFREY J (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:J
Last Name:GORSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S GRAND BLVD
Mailing Address - Street 2:DRC-8
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1015
Mailing Address - Country:US
Mailing Address - Phone:314-977-5500
Mailing Address - Fax:314-771-3816
Practice Address - Street 1:1225 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-577-8000
Practice Address - Fax:314-977-9196
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37510207RI0200X
MOR4J28207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202773909Medicaid
MO042010247Medicare ID - Type Unspecified
MO202773909Medicaid