Provider Demographics
NPI:1558444976
Name:MARK J GOETHE MD PC
Entity Type:Organization
Organization Name:MARK J GOETHE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOETHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-832-0323
Mailing Address - Street 1:7101 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642
Mailing Address - Country:US
Mailing Address - Phone:989-832-0323
Mailing Address - Fax:989-631-0886
Practice Address - Street 1:7101 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642
Practice Address - Country:US
Practice Address - Phone:989-832-0323
Practice Address - Fax:989-631-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101405876207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2971771Medicaid
E49409Medicare UPIN
N84000001Medicare ID - Type Unspecified