Healthcare Provider Details

I. General information

NPI: 1558305557
Provider Name (Legal Business Name): JERRY BURTON GOOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6027 WALNUT GROVE RD SUITE 203
MEMPHIS TN
38120-2145
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5800
US

V. Phone/Fax

Practice location:
  • Phone: 901-226-5957
  • Fax: 901-226-5940
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number10805
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: