Basic Information
| Provider Information | |||||||||
| NPI: | 1851508964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | GARRETT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 TURNER MCCALL BLVD SW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301655621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065096100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093278 | ||||||||
| FaxNumber: | 7065094600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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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 | 207P00000X | 059417 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 622192462B | 05 | GA | MEDICAID |