Provider Demographics
NPI:1962424481
Name:GOERING, EDWARD KEIM (DO)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:KEIM
Last Name:GOERING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 SE LAKE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2138
Mailing Address - Country:US
Mailing Address - Phone:503-236-2303
Mailing Address - Fax:503-236-2614
Practice Address - Street 1:6564 SE LAKE RD STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2138
Practice Address - Country:US
Practice Address - Phone:503-236-2303
Practice Address - Fax:503-236-2614
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO19450204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG72616Medicare UPIN