1518948629 NPI number — SHERYL P GOODALL NP

Table of content: SHERYL P GOODALL NP (NPI 1518948629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518948629 NPI number — SHERYL P GOODALL NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODALL
Provider First Name:
SHERYL
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1518948629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 OAK ST
Provider Second Line Business Mailing Address:
SUITE 105W
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301-1168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-427-3668
Provider Business Mailing Address Fax Number:
508-427-2610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 OAK ST
Provider Second Line Business Practice Location Address:
SUITE 105W
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-1168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-427-3668
Provider Business Practice Location Address Fax Number:
508-427-2610
Provider Enumeration Date:
11/07/2005

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: 363LA2200X , with the licence number:  170600 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0809X , with the licence number: 170600 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 616882 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0355241 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28308 . This is a "HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: PN0849 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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