Basic Information
| Provider Information | |||||||||
| NPI: | 1821415894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOLDRICK | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | SPENCER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPENCER | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | CAROLINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1821 S STOUGHTON RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537162257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082606000 | ||||||||
| FaxNumber: | 6082606855 | ||||||||
| Practice Location | |||||||||
| Address1: | 1821 S STOUGHTON RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537162257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082606000 | ||||||||
| FaxNumber: | 6082606855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2014 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RR0500X | MD181961 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1821415894 | 05 | WI | MEDICAID |