Provider Demographics
NPI:1770874117
Name:GORMAN, MATTHEW WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:GORMAN
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 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:8100 W 78TH ST
Practice Address - Street 2:STE. 230
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2516
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55294207Q00000X, 207RS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400221432Medicare PIN