Basic Information
| Provider Information | |||||||||
| NPI: | 1881678399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOOSSENS | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | BARRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357161000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 N 500 E | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357161000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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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 | 207R00000X | 10886108-1205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CC8362 | 01 | NY | RR MEDICARE GROUP | OTHER | 110225752 | 01 | NY | RR MEDICARE PIN | OTHER | GU040042 | 01 | PA | MEDICARE GROUP | OTHER |