Provider Demographics
NPI:1265713838
Name:GOFF, MICHAEL THOMAS JR (PTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:GOFF
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:40 UNION CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-8336
Mailing Address - Country:US
Mailing Address - Phone:601-384-8179
Mailing Address - Fax:601-384-3196
Practice Address - Street 1:40 UNION CHURCH RD
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653-8336
Practice Address - Country:US
Practice Address - Phone:601-384-8179
Practice Address - Fax:601-384-3196
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA 4044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPTA 4044Medicare UPIN