MEDICARE: MITCHELL GOOZDICH III DC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC.2965	OH

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00004067	OTHER		RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4401426	OTHER		UNITED HEALTHCARE
4	000000257051	OTHER	OH	ANTHEM BLUE CROSS
5	7757699	OTHER		CIGNA

NPI Number	:	1073508503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL GOOZDICH III DC

Provider Business Mailing Address
First Line	:	113 N LEAVITT RD
Second Line	:
City	:	AMHERST
State	:	OH
Zip	:	44001-1110
Country	:	US
Telephone Number	:	440-985-5505
Fax Number	:	440-985-5507

Provider Business Practice Location Address
First Line	:	113 N LEAVITT RD
Second Line	:
City	:	AMHERST
State	:	OH
Zip	:	44001-1110
Country	:	US
Telephone Number	:	440-985-5505
Fax Number	:	440-985-5507

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	07/08/2007

113 N LEAVITT RD
AMHERST, OH
44001-1110

Practice Phone: 440-985-5505
Practice Fax: 440-985-5507