Provider Demographics
NPI:1144371261
Name:GAETHKE, SARAH LYNE GODBERT (MD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:LYNE GODBERT
Last Name:GAETHKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:L
Other - Last Name:GODBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-1700
Practice Address - Country:US
Practice Address - Phone:262-375-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50722-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35307800Medicaid
WI117373601Medicare PIN
WIK400176894Medicare PIN
WI683750716Medicare PIN
WIK400176893Medicare PIN