Provider Demographics
NPI:1942404348
Name:JOHN T. GOLDEN, M.D.
Entity Type:Organization
Organization Name:JOHN T. GOLDEN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-776-0808
Mailing Address - Street 1:25990 KELLY RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4483
Mailing Address - Country:US
Mailing Address - Phone:586-776-0808
Mailing Address - Fax:586-771-0953
Practice Address - Street 1:25990 KELLY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4483
Practice Address - Country:US
Practice Address - Phone:586-776-0808
Practice Address - Fax:586-771-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJG052077208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2665188Medicaid
MIE49663Medicare UPIN
MI2665188Medicaid