Basic Information
| Provider Information | |||||||||
| NPI: | 1366509978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOETZ | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | SIMON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2831 | ||||||||
| Address2: | WEST VIRGINIA GASTROENTEROLOGY & ENDOSCOPY | ||||||||
| City: | ELKINS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262412831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046372360 | ||||||||
| FaxNumber: | 3046372362 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 N 4TH ST | ||||||||
| Address2: | SUITE 300N | ||||||||
| City: | MARTINS FERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439351648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406334765 | ||||||||
| FaxNumber: | 7406336450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 03/20/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 01047428 | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 24647 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 200264500A | 05 | IN | MEDICAID | 3810021993 | 05 | WV | MEDICAID |