1568442465 NPI number — GAIL R GOODMAN M.D.

Table of content: GAIL R GOODMAN M.D. (NPI 1568442465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568442465 NPI number — GAIL R GOODMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
GAIL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1568442465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3675 SOUTHWESTERN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-1732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-972-0279
Provider Business Mailing Address Fax Number:
716-972-0273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3675 SOUTHWESTERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORCHARD PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14127-1732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-972-0279
Provider Business Practice Location Address Fax Number:
716-972-0273
Provider Enumeration Date:
01/18/2006

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:  194330 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00010065904 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01477605 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040426002662 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1211151 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 147716DL . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 479993 . This is a "WELLCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000524370006 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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