Healthcare Provider Details

I. General information

NPI: 1205182136
Provider Name (Legal Business Name): MICHAEL JOSEPH GOULD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 TOWN RUN RD
FAIRMOUNT CITY PA
16224-1502
US

IV. Provider business mailing address

310 GREENCREST DR
SHIPPENVILLE PA
16254-4208
US

V. Phone/Fax

Practice location:
  • Phone: 814-275-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT014570
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: