Healthcare Provider Details

I. General information

NPI: 1275570012
Provider Name (Legal Business Name): GOSHEN ORTHOPEDIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1824 DORCHESTER CT
GOSHEN IN
46526-6476
US

IV. Provider business mailing address

1824 DORCHESTER CT
GOSHEN IN
46526-6476
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-2548
  • Fax: 574-534-3622
Mailing address:
  • Phone: 574-534-2548
  • Fax: 574-534-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA D FLAGG
Title or Position: ADMINISTRATOR
Credential:
Phone: 574-534-2548