Provider Demographics
NPI:1396740395
Name:GORRES, GEOFFREY H (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:H
Last Name:GORRES
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 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3261
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 E STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-483-3261
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080143982OtherPALMETTO GBQ RR MEDICARE
WI32527300Medicaid
WIH03336Medicare UPIN
080143982OtherPALMETTO GBQ RR MEDICARE
1022235OtherPREFERRED ONE