Basic Information
| Provider Information | |||||||||
| NPI: | 1124044771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORREY | ||||||||
| FirstName: | PURUSHOTHAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 277 ROY CAMPBELL DR | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064351708 | ||||||||
| FaxNumber: | 6064352445 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N BRIGHTLEAF BLVD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199387189 | ||||||||
| FaxNumber: | 9199341761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 40269 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 40269 | 01 | KY | MD LICENSURE | OTHER | 64129406 | 05 | KY | MEDICAID |