Provider Demographics
NPI:1558305557
Name:GOOCH, JERRY BURTON (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:BURTON
Last Name:GOOCH
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 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6027 WALNUT GROVE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2145
Practice Address - Country:US
Practice Address - Phone:901-226-5957
Practice Address - Fax:901-226-5940
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10805208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016196Medicaid
MO201015716Medicaid
MO201015716Medicaid
TN3171433Medicaid
MS09016196Medicaid
TN3713059Medicaid
TN060047520Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MS00117424Medicaid
TN621545731OtherBMG METRO CARDIOVASCULAR & THORACIC SURGERY
MO201015716Medicaid
TN3083335OtherBCBS
TN3171433Medicare ID - Type UnspecifiedMCR INDIVIDUAL NUMBER
AR110930001Medicaid