Provider Demographics
NPI:1750367322
Name:GOECKE, SCOTT A (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:GOECKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4083
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-4083
Mailing Address - Country:US
Mailing Address - Phone:701-426-8848
Mailing Address - Fax:
Practice Address - Street 1:2422 20TH ST SW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-6201
Practice Address - Country:US
Practice Address - Phone:701-952-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46454207P00000X
ND8050207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10780Medicaid
NDN712009OtherMEDICARE NUMBER
NDN712009OtherMEDICARE NUMBER