Healthcare Provider Details

I. General information

NPI: 1205174737
Provider Name (Legal Business Name): JUSTIN R. GOEBEL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BURNEY DR
FLOWOOD MS
39232-6621
US

IV. Provider business mailing address

PO BOX 1826
PELHAM AL
35124-5826
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-8200
  • Fax: 601-987-8211
Mailing address:
  • Phone: 205-621-3778
  • Fax: 205-621-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00492
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: