Provider Demographics
NPI:1568587202
Name:RL GOETHKE MD SC
Entity Type:Organization
Organization Name:RL GOETHKE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOETHKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-731-4101
Mailing Address - Street 1:PO BOX 8031
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8031
Mailing Address - Country:US
Mailing Address - Phone:866-313-0337
Mailing Address - Fax:920-739-0124
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-731-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty