Basic Information
| Provider Information | |||||||||
| NPI: | 1306827126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOECKER | ||||||||
| FirstName: | GOETZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025894856 | ||||||||
| FaxNumber: | 5025895093 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025624370 | ||||||||
| FaxNumber: | 5025624373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 33111 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 64331119 | 05 | KY | MEDICAID |