Basic Information
| Provider Information | |||||||||
| NPI: | 1992708564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOEB | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116 | ||||||||
| Address2: | |||||||||
| City: | CROMWELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557260116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Practice Location | |||||||||
| Address1: | 5565 HIGHWAY 210 | ||||||||
| Address2: | |||||||||
| City: | CROMWELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557268171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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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 | 207Q00000X | 40702 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 695715300 | 05 | MN | MEDICAID |