MEDICARE: MR. MICHAEL WAYNE GOFORTH ATC

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	2255A2300X	Athletic Trainer	0126000314	VA

General Provider Information

NPI Number	:	1679539324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL WAYNE GOFORTH ATC

Provider Business Mailing Address
First Line	:	3260 GORDON DR
Second Line	:
City	:	BLACKSBURG
State	:	VA
Zip	:	24060-8675
Country	:	US
Telephone Number	:	540-953-0266
Fax Number	:

Provider Business Practice Location Address
First Line	:	VIRGINIA TECH SPORTS MEDICINE, 113 MERRYMAN CENTER
Second Line	:
City	:	BLACKSBURG
State	:	VA
Zip	:	24061-0001
Country	:	US
Telephone Number	:	540-231-7742
Fax Number	:

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

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	07/21/2022

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