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NPI Code Detail

MEDICARE: MR. JOHN JOSEPH GOEDERT III PA-C

MEDICARE: MR. JOHN JOSEPH GOEDERT III PA-C
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant10001845AIN
2363A00000XPhysician AssistantTC699KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1295118446
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JOHN JOSEPH GOEDERT III PA-C
Provider Business Mailing Address
First Line : PO BOX 23229
Second Line :
City : OWENSBORO
State : KY
Zip : 42304-3229
Country : US
Telephone Number : 270-691-8070
Fax Number : 270-691-8026
Provider Business Practice Location Address
First Line : 1200 BARRETT BLVD
Second Line :
City : HENDERSON
State : KY
Zip : 42420-4950
Country : US
Telephone Number : 270-844-8600
Fax Number : 270-844-8610
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2015
Last Update Date : 04/23/2018

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