Provider Demographics
NPI:1720330392
Name:GINA GORA M D PLLC
Entity Type:Organization
Organization Name:GINA GORA M D PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-872-1526
Mailing Address - Street 1:3347 WORMER DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2569
Mailing Address - Country:US
Mailing Address - Phone:248-872-1526
Mailing Address - Fax:
Practice Address - Street 1:3347 WORMER DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-2569
Practice Address - Country:US
Practice Address - Phone:248-872-1526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty