Provider Demographics
NPI:1114960101
Name:MCGOLDRICK, JUSTIN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:B
Last Name:MCGOLDRICK
Suffix:
Gender:M
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:PO BOX 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5281
Practice Address - Country:US
Practice Address - Phone:865-471-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35270207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3865961Medicaid
TN4150060OtherBLUE CROSS
TN4014592OtherBLUE CROSS
TNP00189111OtherRAILROAD MEDICARE
TN3865960Medicaid
TN3865961Medicare PIN
TN4150060OtherBLUE CROSS
TN4014592OtherBLUE CROSS