Provider Demographics
NPI:1508807876
Name:GORE, STEPHEN T (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:GORE
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 1:286 WILMORE DR
Mailing Address - Street 2:
Mailing Address - City:WHITE PINE
Mailing Address - State:TN
Mailing Address - Zip Code:37890-4734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 W 4TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814
Practice Address - Country:US
Practice Address - Phone:423-586-4231
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400256207P00000X
TN0101050730208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508807876Medicaid
NCNCV266AOtherMEDICARE PTAN
TN3011285Medicaid
KY64922552Medicaid
TN103I939481Medicare PIN
NCNCV266AOtherMEDICARE PTAN
KY64922552Medicaid