1518083732 NPI number — AMY MORGAN GOODE PAC

Table of content: AMY MORGAN GOODE PAC (NPI 1518083732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518083732 NPI number — AMY MORGAN GOODE PAC

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRADFORD
Provider Other First Name:
AMY
Provider Other Middle Name:
MORGAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518083732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
365 COURTHOUSE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-425-3922
Provider Business Mailing Address Fax Number:
304-487-0229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 COURTHOUSE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-425-3922
Provider Business Practice Location Address Fax Number:
304-487-0229
Provider Enumeration Date:
03/21/2007

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810017069 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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