Provider Demographics
NPI:1396759940
Name:GOENS, BRUCE M (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:GOENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11725 N ILLINOIS ST
Practice Address - Street 2:STE 325
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3002
Practice Address - Country:US
Practice Address - Phone:317-688-5800
Practice Address - Fax:317-688-5805
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01027055A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00887146OtherRAILROAD MEDICARE PTAN
IN000000313300OtherANTHEM
IN100062890Medicaid
INP00081860OtherRR MEDICARE
IN215060AMedicare PIN
IN100062890Medicaid
INP00081860OtherRR MEDICARE