Provider Demographics
NPI:1720198161
Name:GOURIN, CHRISTINE G (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:G
Last Name:GOURIN
Suffix:
Gender:F
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:PO BOX 64588
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4588
Mailing Address - Country:US
Mailing Address - Phone:410-614-0609
Mailing Address - Fax:
Practice Address - Street 1:601 N CAROLINE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-614-0609
Practice Address - Fax:410-614-8610
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049449207Y00000X
MDD0066673207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD015804600Medicaid
GA000891954AMedicaid
SCG49449Medicaid
MD766631400Medicaid
MD015804600Medicaid
MDKR60R534Medicare PIN
MD766631400Medicaid