Provider Demographics
NPI:1811964265
Name:GOEDECKE, ERIC (DO)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:GOEDECKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:TURNPIKE STATION
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-0062
Mailing Address - Country:US
Mailing Address - Phone:508-334-8815
Mailing Address - Fax:508-334-5374
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-5426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221572207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2108615Medicaid
MA2108615Medicaid
MAGO A39051Medicare ID - Type Unspecified