Provider Demographics
NPI:1093823908
Name:GOSHEN SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:GOSHEN SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-533-2769
Mailing Address - Street 1:101 MARILYN AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4800
Mailing Address - Country:US
Mailing Address - Phone:574-533-2769
Mailing Address - Fax:574-534-6822
Practice Address - Street 1:101 MARILYN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4800
Practice Address - Country:US
Practice Address - Phone:574-533-2769
Practice Address - Fax:574-534-6822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50001564A208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100384730Medicaid
IN208030Medicare PIN