=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366638835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA GOEBEL D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11786 SE FEDERAL HWY
-----------------------------------------------------
City | HOBE SOUND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33455-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-546-4215
-----------------------------------------------------
Fax | 772-546-8741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11786 SE FEDERAL HWY
-----------------------------------------------------
City | HOBE SOUND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33455-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-546-4215
-----------------------------------------------------
Fax | 772-546-8741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS8519
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------