Provider Demographics
NPI:1174685101
Name:GORUM, MICHAEL WREN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WREN
Last Name:GORUM
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 1:1538 13TH AVE
Mailing Address - Street 2:STE B300
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2563
Mailing Address - Country:US
Mailing Address - Phone:706-321-9300
Mailing Address - Fax:706-321-9384
Practice Address - Street 1:1538 13TH. AVE.
Practice Address - Street 2:SUITE B300
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3700
Practice Address - Country:US
Practice Address - Phone:706-321-9300
Practice Address - Fax:706-321-9384
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA44471207T00000X
AL13389193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No193400000XGroupSingle Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000766004BMedicaid
GA367345OtherBCBS PROVIDER NUMBER
GA367345OtherBCBS PROVIDER NUMBER
GA000766004BMedicaid