Provider Demographics
NPI:1992020366
Name:MARY S. GOSWITZ MD, PA
Entity Type:Organization
Organization Name:MARY S. GOSWITZ MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:GOSWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-420-8557
Mailing Address - Street 1:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77522-1297
Mailing Address - Country:US
Mailing Address - Phone:281-420-8557
Mailing Address - Fax:281-427-2911
Practice Address - Street 1:4021 GARTH RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3160
Practice Address - Country:US
Practice Address - Phone:281-420-8557
Practice Address - Fax:281-427-2911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ69722085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0018GKOtherBCBS
TX103039703Medicaid
10017453OtherAMERIGROUP
0018GKOtherBCBS