1104028489 NPI number — GOODMAN MEDICAL CENTER PC

Table of content: (NPI 1104028489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104028489 NPI number — GOODMAN MEDICAL CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODMAN MEDICAL CENTER PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104028489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 918
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65402-0918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-308-5044
Provider Business Mailing Address Fax Number:
573-341-5300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 STATE ROUTE CC
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROLLA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65401-4402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-308-5044
Provider Business Practice Location Address Fax Number:
573-341-5300
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
KARENE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
COOWNER
Authorized Official Telephone Number:
573-308-5044

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500447206 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG5099 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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