Provider Demographics
NPI:1104831064
Name:NEIL E GOODMAN MD PC
Entity Type:Organization
Organization Name:NEIL E GOODMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-554-0544
Mailing Address - Street 1:2500 STARLING ST
Mailing Address - Street 2:SUITE # 401
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4219
Mailing Address - Country:US
Mailing Address - Phone:912-554-0544
Mailing Address - Fax:912-554-0344
Practice Address - Street 1:2500 STARLING ST
Practice Address - Street 2:SUITE # 401
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4219
Practice Address - Country:US
Practice Address - Phone:912-554-0544
Practice Address - Fax:912-554-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034143208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00714876GMedicaid
GA034143OtherSTATE MED LIC NUMBER
GABG2811467OtherDEA NUMBER