Provider Demographics
NPI:1154315083
Name:GOUSE, JOHN CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CONRAD
Last Name:GOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 WATERS AVE
Mailing Address - Street 2:SUITE C8
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3825
Mailing Address - Country:US
Mailing Address - Phone:919-352-2606
Mailing Address - Fax:912-352-0629
Practice Address - Street 1:7505 WATERS AVE
Practice Address - Street 2:SUITE C8
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3825
Practice Address - Country:US
Practice Address - Phone:912-352-2606
Practice Address - Fax:912-352-0623
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0285582085B0100X, 2085N0904X, 2085P0229X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA023574OtherBLUE CROSS
GA00330536AMedicaid
SCG28558Medicaid
GA30016960OtherKEYSTONE MERCY
SCG28558Medicaid
GA00330536AMedicaid
GA30CDBHZMedicare ID - Type UnspecifiedMEDICARE