Provider Demographics
NPI:1427049303
Name:GOEDECKE, PHILLIP ARTHUR (DC)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:ARTHUR
Last Name:GOEDECKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19605-2567
Mailing Address - Country:US
Mailing Address - Phone:610-929-1115
Mailing Address - Fax:
Practice Address - Street 1:2851 CENTRE AVE
Practice Address - Street 2:STE 4
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19605-2567
Practice Address - Country:US
Practice Address - Phone:610-929-1115
Practice Address - Fax:610-929-3548
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003941L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
01963101OtherBLUE CROSS
1031982OtherASHN
BE1606382OtherBLUE SHIELD
PA608513Medicare ID - Type Unspecified