1568481356 NPI number — DR. GLENN LEE GOODHART M.D.

Table of content: DR. GLENN LEE GOODHART M.D. (NPI 1568481356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568481356 NPI number — DR. GLENN LEE GOODHART M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODHART
Provider First Name:
GLENN
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1568481356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CORPORATE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-893-9698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40100 HIGHWAY 27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33837-5906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-422-4971
Provider Business Practice Location Address Fax Number:
863-419-2264
Provider Enumeration Date:
07/19/2006

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: 207R00000X , with the licence number:  MD-43462 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: D29594 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME116577 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 19386 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: MD034685L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00213694A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 019386 . This is a "LICENSE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 85001797G . This is a "GEORGIA BETTER HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 854101 . This is a "CIGNA ID NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2027755 . This is a "AETNA US GROUP NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 9206456 . This is a "UNITED HEALTHCARE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52241370 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52241370 . This is a "STATE HEALTH BENEFIT" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 010629200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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