Healthcare Provider Details

I. General information

NPI: 1568587202
Provider Name (Legal Business Name): RL GOETHKE MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

PO BOX 8031
APPLETON WI
54912-8031
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4101
  • Fax:
Mailing address:
  • Phone: 866-313-0337
  • Fax: 920-739-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: RANDAL L GOETHKE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 920-731-4101