Provider Demographics
NPI:1558392068
Name:GORMLEY, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:GORMLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:200 UNIVERSITY AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2507
Mailing Address - Country:US
Mailing Address - Phone:651-229-3819
Mailing Address - Fax:651-265-7443
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2507
Practice Address - Country:US
Practice Address - Phone:651-229-3819
Practice Address - Fax:651-265-7443
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN36551208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN726263900Medicaid
MN726263900Medicaid
D76838Medicare UPIN