1255872933 NPI number — AMANDA GLYNN GOETHALS D.O.

Table of content: MARCELINA PEREZ (NPI 1558025379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255872933 NPI number — AMANDA GLYNN GOETHALS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOETHALS
Provider First Name:
AMANDA
Provider Middle Name:
GLYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1255872933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 20TH AVE N STE 403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203-5180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-284-4672
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7007 POWERS BOULEVARD
Provider Second Line Business Practice Location Address:
UNIVERSITY PARMA MEDICAL CENTER
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-743-3006
Provider Business Practice Location Address Fax Number:
440-743-2131
Provider Enumeration Date:
03/15/2017

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 3933 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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