1669454948 NPI number — DR. TIMOTHY B GOODWIN M.D.

Table of content: DR. TIMOTHY B GOODWIN M.D. (NPI 1669454948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669454948 NPI number — DR. TIMOTHY B GOODWIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODWIN
Provider First Name:
TIMOTHY
Provider Middle Name:
B
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:
1669454948
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 851897
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36685-1897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-476-8646
Provider Business Mailing Address Fax Number:
919-382-3210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 AIRPORT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-476-8646
Provider Business Practice Location Address Fax Number:
919-382-3210
Provider Enumeration Date:
11/14/2005

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: 174400000X , with the licence number:  16345 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51088197 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 107125300 . 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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