Basic Information
| Provider Information | |||||||||
| NPI: | 1295152189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOEDTEL BIRR | ||||||||
| FirstName: | STACEE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOEDTEL | ||||||||
| OtherFirstName: | STACEE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 853 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OCONTO FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 229 S MORRISON ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549115725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208322783 | ||||||||
| FaxNumber: | 9208322635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 06/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 65320-21 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.