Provider Demographics
NPI:1518935121
Name:GORMAN, ROBERT ROLAND III (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ROLAND
Last Name:GORMAN
Suffix:III
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 1:601 JOHN ST
Mailing Address - Street 2:SUITE M401
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:855-618-2676
Mailing Address - Fax:269-488-3241
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M401
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:855-618-2676
Practice Address - Fax:269-488-3241
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072238207X00000X, 207XX0004X
NMMD2004-0315207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5194435Medicaid
MI1417961137OtherBCBSM - BMH
MI1518935121Medicaid
MIC97618252Medicare PIN
MIC97618252 - BMHMedicare PIN
MI5194435Medicaid
MI0C97625099Medicare PIN