1922011246 NPI number — DR. JESSE ADAM GOODMAN M.D.

Table of content: DR. JESSE ADAM GOODMAN M.D. (NPI 1922011246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922011246 NPI number — DR. JESSE ADAM GOODMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
JESSE
Provider Middle Name:
ADAM
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:
1922011246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 CHURCH ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LENOX
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01240-2525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-637-2300
Provider Business Mailing Address Fax Number:
413-315-5276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38 CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LENOX
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01240-2525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-637-2300
Provider Business Practice Location Address Fax Number:
888-443-7405
Provider Enumeration Date:
08/15/2006

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: 2084P0800X , with the licence number:  160625 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J26890 . This is a "BLUE CROSS BLUE SHIELD OF MASSACHUSETTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2299118580 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2021528 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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