Basic Information
| Provider Information | |||||||||
| NPI: | 1588609499 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOREN | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W BROADWAY ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295615 | ||||||||
| FaxNumber: | 4063295606 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W BROADWAY ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295615 | ||||||||
| FaxNumber: | 4063295606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 6208 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0041395 | 05 | MT | MEDICAID |