Provider Demographics
NPI:1083670665
Name:GOECKERMANN, CHERYL R (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:R
Last Name:GOECKERMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-3319
Mailing Address - Country:US
Mailing Address - Phone:608-355-3800
Mailing Address - Fax:608-355-7001
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:608-355-3800
Practice Address - Fax:608-355-7001
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38184-020207Q00000X
WI38184-20207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083670665Medicaid
WI080121398OtherRAILROAD MEDICARE
WIK400176250Medicare PIN
G44136Medicare UPIN
WI32302700Medicaid
WI080178999Medicare PIN
WI009913215Medicare PIN