Provider Demographics
NPI:1073703260
Name:TIMOTHY A GOEDDE MD PC
Entity Type:Organization
Organization Name:TIMOTHY A GOEDDE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOEDDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-288-2456
Mailing Address - Street 1:7430 N SHADELAND AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2036
Mailing Address - Country:US
Mailing Address - Phone:317-288-2456
Mailing Address - Fax:317-288-2461
Practice Address - Street 1:7430 N SHADELAND AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2036
Practice Address - Country:US
Practice Address - Phone:317-288-2456
Practice Address - Fax:317-288-2461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200870480AMedicaid
IN252240Medicare PIN