Basic Information
| Provider Information | |||||||||
| NPI: | 1306826615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOSS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 19035 W CAPITOL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627541421 | ||||||||
| FaxNumber: | 2627543760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25934-020 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31550000 | 05 | WI | MEDICAID |