Provider Demographics
NPI:1003872219
Name:GOETTER, STEPHEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:GOETTER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:304 W HAY ST
Practice Address - Street 2:STE 312
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6328
Practice Address - Country:US
Practice Address - Phone:217-876-5600
Practice Address - Fax:217-876-5664
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036055312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04855Medicare ID - Type Unspecified
ILC37390Medicare UPIN