1528164738 NPI number — BRUCE C GOLDSWORTHY DC

Table of content: BRUCE C GOLDSWORTHY DC (NPI 1528164738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528164738 NPI number — BRUCE C GOLDSWORTHY DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSWORTHY
Provider First Name:
BRUCE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1528164738
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 S 32ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54401-3958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-848-2526
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
941 CENTURY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTIGO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54409-2484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-623-7141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2006

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: 111N00000X , with the licence number:  1660-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CJ7401 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 13056 . This is a "SECURITY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 38884300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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