Provider Demographics
NPI:1972576775
Name:GORMAN, MARY JO (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:999 EXECUTIVE PARKWAY DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6336
Mailing Address - Country:US
Mailing Address - Phone:314-514-6000
Mailing Address - Fax:314-514-6020
Practice Address - Street 1:12303 DEPAUL DRIVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-5536
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:314-514-6020
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2009-03-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR5G50207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE56435Medicare UPIN
MO003012671Medicare PIN