Basic Information
| Provider Information | |||||||||
| NPI: | 1053335992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERSHMAN-TEWKSBURY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1820 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047691820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077647529 | ||||||||
| FaxNumber: | 2077646504 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077684209 | ||||||||
| FaxNumber: | 2077684013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 012546 | ME | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003962 | 01 | ME | ANTHEM INDIVIDUAL ID | OTHER |