1154483089 NPI number — DR. CHARLES MICHAEL GODDARD II MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154483089 NPI number — DR. CHARLES MICHAEL GODDARD II MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODDARD
Provider First Name:
CHARLES
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
Provider Credential Text:
MD
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:
1154483089
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:
7275 SAWMILL ROAD
Provider Second Line Business Mailing Address:
NORTHWEST PEDIATRICS, INC.
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-766-6321
Provider Business Mailing Address Fax Number:
614-766-0193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7275 SAWMILL ROAD
Provider Second Line Business Practice Location Address:
NORTHWEST PEDIATRICS, INC.
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-766-6321
Provider Business Practice Location Address Fax Number:
614-766-0193
Provider Enumeration Date:
12/15/2006

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: 208000000X , with the licence number:  059637 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 069707 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11293017 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 328339 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69707 . This is a "OH LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 059637 . This is a "MI LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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