Provider Demographics
NPI:1285893891
Name:GORMAN, KELLY S (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:S
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-3649
Mailing Address - Fax:
Practice Address - Street 1:1030 MCINTOSH CIR
Practice Address - Street 2:STE 1
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3614
Practice Address - Country:US
Practice Address - Phone:417-347-8750
Practice Address - Fax:417-347-8788
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN8725208000000X
MO2014008958208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics