Healthcare Provider Details

I. General information

NPI: 1124024088
Provider Name (Legal Business Name): RAE JEANNA GODSEY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

2100 MARKET ST STE 100
CHARLESTOWN IN
47111-9535
US

IV. Provider business mailing address

1502 TUNNEL MILL RD
CHARLESTOWN IN
47111-9216
US

V. Phone/Fax

Practice location:
  • Phone: 812-256-0700
  • Fax: 812-256-0704
Mailing address:
  • Phone: 812-256-0700
  • Fax: 812-256-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02002615A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: