Provider Demographics
NPI:1255483079
Name:GORMAN, JIM F (MC)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:F
Last Name:GORMAN
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 EAST RILEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323
Mailing Address - Country:US
Mailing Address - Phone:623-832-7407
Mailing Address - Fax:623-932-1884
Practice Address - Street 1:530 EAST RILEY DRIVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-832-7407
Practice Address - Fax:623-932-1884
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ594722OtherAHCCCS MEMBERS
AZ588668OtherPROVIDER ID NUMBER