1457454720 NPI number — MR. PHILLIP D GOODSON RPH

Table of content: MR. PHILLIP D GOODSON RPH (NPI 1457454720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457454720 NPI number — MR. PHILLIP D GOODSON RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODSON
Provider First Name:
PHILLIP
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1457454720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAWSONVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30534-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-265-2020
Provider Business Mailing Address Fax Number:
706-265-2987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 HIGHWAY 53 WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAWSONVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30534-0004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-265-2020
Provider Business Practice Location Address Fax Number:
706-265-2987
Provider Enumeration Date:
09/05/2006

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: 183500000X , with the licence number:  RPH010965 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000119677A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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