Basic Information
| Provider Information | |||||||||
| NPI: | 1932213204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORRIE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVENUE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179630860 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 714 N. SENATE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179441837 | ||||||||
| FaxNumber: | 3177156415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 36113813 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 02003492A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | OS18237 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00787056 | 01 | IN | RAILROAD MEDICARE | OTHER | 112658900 | 05 | FL | MEDICAID | 000000618591 | 01 | IN | ANTHEM BCBS | OTHER | 200946010 | 05 | IN | MEDICAID |