MEDICARE: CORY GOOCH

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
1	171M00000X	Case Manager/Care Coordinator
2	172A00000X	Driver

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487245460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY GOOCH

Provider Business Mailing Address
First Line	:	4909 SHELBURNE ST
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58503-5605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	193 24TH ST E STE 103
Second Line	:
City	:	DICKINSON
State	:	ND
Zip	:	58601-6580
Country	:	US
Telephone Number	:	701-223-2417
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2021
Last Update Date	:	04/15/2021

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Directions to “ CORY GOOCH ” Practice Location

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