Healthcare Provider Details

I. General information

NPI: 1093823908
Provider Name (Legal Business Name): GOSHEN SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MARILYN AVE SUITE 4
GOSHEN IN
46526-4800
US

IV. Provider business mailing address

101 MARILYN AVE SUITE 4
GOSHEN IN
46526-4800
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-2769
  • Fax: 574-534-6822
Mailing address:
  • Phone: 574-533-2769
  • Fax: 574-534-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number50001564A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number50001564A
License Number StateIN

VIII. Authorized Official

Name: JOHN W HARLEY
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 574-533-2769