Provider Demographics
NPI:1164432720
Name:GORSKI, JEROME L (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:GORSKI
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:402 N KEENE ST
Practice Address - Street 2:STE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6986
Practice Address - Country:US
Practice Address - Phone:573-882-6921
Practice Address - Fax:573-882-1154
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2206028760208000000X
MI4301049958207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206268807Medicaid
MI1736383Medicaid
MO206268807Medicaid
MO962390635Medicare PIN
MI1736383Medicaid
A79111Medicare UPIN