Provider Demographics
NPI:1275547564
Name:GOOCH, KENNETH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:GOOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:L
Other - Last Name:GOOCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-264-6000
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-264-6000
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12115207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111737Medicaid
MS5360131OtherAETNA
MS5360131OtherAETNA
MSP00370736OtherRAILROAD MEDICARE
MSP00975881OtherRAILROAD MEDICARE
MS512I930409Medicare PIN
MS302I935923Medicare PIN
MS930003638Medicare PIN
MS00111737Medicaid