Provider Demographics
NPI:1184039836
Name:GOETTER, MICHAEL LEE (DPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:GOETTER
Suffix:
Gender:M
Credentials:DPT
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF NEUROSURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5400
Mailing Address - Fax:414-955-0115
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF NEUROSURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5400
Practice Address - Fax:414-955-0115
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI12714-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184039836Medicaid