Basic Information
| Provider Information | |||||||||
| NPI: | 1023291812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIRK A. GOUGE, D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1004 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604571500 | ||||||||
| FaxNumber: | 3604571599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604571500 | ||||||||
| FaxNumber: | 3604571599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2007 | ||||||||
| LastUpdateDate: | 12/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | KIESSER | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLAIMS BILLER | ||||||||
| AuthorizedOfficialTelephone: | 3604571500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | OP00001549 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7116429 | 05 | WA | MEDICAID |