Basic Information
| Provider Information | |||||||||
| NPI: | 1538133863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORMLEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725100 | ||||||||
| FaxNumber: | 5022725114 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 KRESGE WAY | ||||||||
| Address2: | SUITE 51-A | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028918981 | ||||||||
| FaxNumber: | 5028914548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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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 | 208100000X | 35530 | KY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2438719000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 4881531 | 01 | KY | CIGNA-NRP | OTHER | 009597 | 01 | KY | SIHO-NRP | OTHER | 400040047 | 01 | KY | MEDICARE PTAN -- NRP | OTHER | 50031805 | 01 | KY | PASSPORT HEALTH -NRP | OTHER | 200253020 | 05 | IN | MEDICAID | M400053460 | 01 | IN | MEDICARE PTAN- NORTON REHAB. PHYSICIANS | OTHER | 000000210852 | 01 | KY | ANTHEM PROVIDER # | OTHER | 000000694535 | 01 | KY | ANTHEM-NRP | OTHER | 000057080Z | 01 | KY | HUMANA-NRP | OTHER | 64002199 | 05 | KY | MEDICAID | 1152901 | 01 | KY | PASSPORT | OTHER |