1104831064 NPI number — NEIL E GOODMAN MD PC

Table of content: (NPI 1104831064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104831064 NPI number — NEIL E GOODMAN MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEIL E GOODMAN MD 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:
1104831064
Entity Type Code:
Organization
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:
2500 STARLING ST
Provider Second Line Business Mailing Address:
SUITE # 401
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31520-4219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-554-0544
Provider Business Mailing Address Fax Number:
912-554-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 STARLING ST
Provider Second Line Business Practice Location Address:
SUITE # 401
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-554-0544
Provider Business Practice Location Address Fax Number:
912-554-0344
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
EVAN
Authorized Official Title or Position:
PRESIDENT / OWNER
Authorized Official Telephone Number:
912-554-0544

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  034143 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2080A0000X , with the licence number: 034143 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 00714876G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 034143 . This is a "STATE MED LIC NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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