1366509978 NPI number — DR. GEORGE SIMON GOETZ MD

Table of content: DR. GEORGE SIMON GOETZ MD (NPI 1366509978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366509978 NPI number — DR. GEORGE SIMON GOETZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOETZ
Provider First Name:
GEORGE
Provider Middle Name:
SIMON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366509978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2831
Provider Second Line Business Mailing Address:
WEST VIRGINIA GASTROENTEROLOGY & ENDOSCOPY
Provider Business Mailing Address City Name:
ELKINS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26241-2831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-637-2360
Provider Business Mailing Address Fax Number:
304-637-2362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 N 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 300N
Provider Business Practice Location Address City Name:
MARTINS FERRY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43935-1648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-633-4765
Provider Business Practice Location Address Fax Number:
740-633-6450
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  01047428 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 24647 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200264500A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810021993 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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