Provider Demographics
NPI:1902589542
Name:GORMAN, ELLIE
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 29TH AVE S APT 435
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-2112
Mailing Address - Country:US
Mailing Address - Phone:205-908-0470
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Practice Address - Street 2:CU2RE PROGRAM
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205
Practice Address - Country:US
Practice Address - Phone:205-908-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program