Basic Information
| Provider Information | |||||||||
| NPI: | 1225009624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3330 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370433330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316475034 | ||||||||
| FaxNumber: | 9315526663 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 N CAROTHERS RD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370675822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157912682 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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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 | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3835637 | 05 | TN | MEDICAID | P00057561 | 01 | RAILROAD MEDICARE | OTHER | 4061461 | 01 | BCBS PROVIDER | OTHER |