Provider Demographics
NPI:1073927372
Name:GOODMAN, ELAINE
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BREEZY CT
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3532
Mailing Address - Country:US
Mailing Address - Phone:410-902-6540
Mailing Address - Fax:410-902-6071
Practice Address - Street 1:13 BREEZY CT
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3532
Practice Address - Country:US
Practice Address - Phone:410-902-6540
Practice Address - Fax:410-902-6071
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR3658332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
521608273OtherFEDERAL TAX ID #