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NPI Code Detail

MEDICARE: JAN BARRY GOOSSENS M.D.

MEDICARE: JAN BARRY GOOSSENS M.D.
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
1207R00000XInternal Medicine Physician10886108-1205UT

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1CC8362OTHERNYRR MEDICARE GROUP
2110225752OTHERNYRR MEDICARE PIN
3GU040042OTHERPAMEDICARE GROUP

General Provider Information

NPI Number : 1881678399
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAN BARRY GOOSSENS M.D.
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number : 435-716-1000
Fax Number :
Provider Business Practice Location Address
First Line : 1400 N 500 E
Second Line :
City : LOGAN
State : UT
Zip : 84341-2455
Country : US
Telephone Number : 435-716-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2005
Last Update Date : 04/26/2019

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