Basic Information
| Provider Information | |||||||||
| NPI: | 1285893891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SWEENEY | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648033810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173473649 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1030 MCINTOSH CIR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173478750 | ||||||||
| FaxNumber: | 4173478788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | TRN8725 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2014008958 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.