Basic Information
| Provider Information | |||||||||
| NPI: | 1578504429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOELLNER | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477105 | ||||||||
| FaxNumber: | 4077700594 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 OLD CAMP RD STE 192 | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321625605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527515514 | ||||||||
| FaxNumber: | 3527531276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 04/26/2013 | ||||||||
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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 | 207P00000X | ME30269 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 92811 | 01 | FL | BLUE SHIELD OF FL | OTHER | 061502100 | 05 | FL | MEDICAID |