Provider Demographics
NPI:1306157490
Name:GORMAN, MARK P (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:57 BEDFORD ST
Practice Address - Street 2:STE 202
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4500
Practice Address - Country:US
Practice Address - Phone:781-541-5111
Practice Address - Fax:781-541-5115
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist