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NPI Code Detail

MEDICARE: TYLER JAMES GOUGE MD

MEDICARE: TYLER JAMES GOUGE MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QS0010XSports Medicine (Family Medicine) Physician2020020734MO

General Provider Information

NPI Number : 1275062432
Entity Type Code : Individual
Provider Name (Legal Business Name) : TYLER JAMES GOUGE MD
Provider Business Mailing Address
First Line : 331 HOSPITAL DR STE A
Second Line :
City : LEBANON
State : MO
Zip : 65536-9251
Country : US
Telephone Number : 417-533-6560
Fax Number :
Provider Business Practice Location Address
First Line : 701 S NEW BALLAS RD STE 510
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63141-8726
Country : US
Telephone Number : 314-251-6710
Fax Number : 314-251-6712
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2017
Last Update Date : 12/08/2023

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