Basic Information
| Provider Information | |||||||||
| NPI: | 1871571893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOERISH | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 E MAIN ST PO BOX 8674 | ||||||||
| Address2: | MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1230 E MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC AT MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 43507 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | NA2951027673 | 01 | MN | PREFERRED ONE | OTHER | 0701675 | 01 | MN | MEDICA | OTHER | 410849339 56001 C183 | 01 | CHAMPUS | OTHER | 729415800 | 05 | MN | MEDICAID | 160054398 | 01 | RR MEDICARE | OTHER | 1694574 | 01 | MN | AMERICAS PPO | OTHER | 45D45GO | 01 | MN | BCBS | OTHER | HP33855 | 01 | MN | HEALTH PARTNERS | OTHER | 151849 | 01 | MN | UCARE | OTHER |