Provider Demographics
NPI:1104956895
Name:GOETHALS, ANDREA JO (DO)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:JO
Last Name:GOETHALS
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:8235 HOLLY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2441
Mailing Address - Country:US
Mailing Address - Phone:810-694-9700
Mailing Address - Fax:810-694-9940
Practice Address - Street 1:8235 HOLLY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2441
Practice Address - Country:US
Practice Address - Phone:810-694-9700
Practice Address - Fax:810-694-9940
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2009-04-29
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Provider Licenses
StateLicense IDTaxonomies
MI5101015223208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114995665Medicaid
MI46149OtherHEALTH PLAN OF MICHIGAN
MI6U10108OtherHEALTH ALLIANCE PLAN
MI01007313OtherHEALTH PLUS
MI0252511984OtherBLUE CROSS
MI0252511984OtherBLUE CARE NETWORK
MI0N89830006OtherBLUE CROSS MEDICARE ADVAN
MI01007313OtherGENESEE HEALTH PLAN
MI382626202OtherAETNA
MI0252511984OtherBLUE CARE NETWORK