1134348329 NPI number — EDWIN BAKER GOODALL III PH.D.

Table of content: EDWIN BAKER GOODALL III PH.D. (NPI 1134348329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134348329 NPI number — EDWIN BAKER GOODALL III PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODALL
Provider First Name:
EDWIN
Provider Middle Name:
BAKER
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134348329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 134
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTER SANDWICH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03227-0134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-284-7174
Provider Business Mailing Address Fax Number:
603-528-2257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 GILFORD AVE
Provider Second Line Business Practice Location Address:
UNIT 103
Provider Business Practice Location Address City Name:
GILFORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03249-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-496-7955
Provider Business Practice Location Address Fax Number:
603-528-2257
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  196 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0602256YONHO1 . This is a "ANTHEM BCBS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 80622256 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com