Provider Demographics
NPI:1104028489
Name:GOODMAN MEDICAL CENTER PC
Entity Type:Organization
Organization Name:GOODMAN MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:573-308-5044
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0918
Mailing Address - Country:US
Mailing Address - Phone:573-308-5044
Mailing Address - Fax:573-341-5300
Practice Address - Street 1:715 STATE ROUTE CC
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4402
Practice Address - Country:US
Practice Address - Phone:573-308-5044
Practice Address - Fax:573-341-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500447206Medicaid
MODG5099OtherRAILROAD MEDICARE
MO990001376Medicare ID - Type UnspecifiedGROUP NUMBER