1982669024 NPI number — DR. GARY R GOODMAN MD

Table of content: DR. GARY R GOODMAN MD (NPI 1982669024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982669024 NPI number — DR. GARY R GOODMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
GARY
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1982669024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 HARRINGTON ST STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT CLEMENS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48043-2967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-493-9229
Provider Business Mailing Address Fax Number:
586-493-4396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22250 PROVIDENCE DR STE 606
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-6214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-443-1281
Provider Business Practice Location Address Fax Number:
248-443-1411
Provider Enumeration Date:
04/20/2006

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: 208G00000X , with the licence number:  4301044225 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10 3282495 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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