1225248784 NPI number — STACY GOODE MD

Table of content: STACY GOODE MD (NPI 1225248784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225248784 NPI number — STACY GOODE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODE
Provider First Name:
STACY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1225248784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91627
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:
36691-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-654-4607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CRESTVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERGREEN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36401-3333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-654-4607
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

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: 207Q00000X , with the licence number:  27479 , 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: 009913532 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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