Healthcare Provider Details

I. General information

NPI: 1306826615
Provider Name (Legal Business Name): MICHAEL P GOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19035 W CAPITOL DR SUITE 101
BROOKFIELD WI
53045-2706
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-1421
  • Fax: 262-754-3760
Mailing address:
  • Phone: 414-423-4100
  • Fax: 414-423-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25934-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: