Healthcare Provider Details

I. General information

NPI: 1396740395
Provider Name (Legal Business Name): GEOFFREY H. GORRES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E STATE ST
SAINT CROIX FALLS WI
54024-4117
US

IV. Provider business mailing address

235 E STATE ST
SAINT CROIX FALLS WI
54024-4117
US

V. Phone/Fax

Practice location:
  • Phone: 715-483-3261
  • Fax: 715-483-0507
Mailing address:
  • Phone: 715-483-3261
  • Fax: 715-483-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36194
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: