Provider Demographics
NPI:1114056389
Name:GOOD MEDICINE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GOOD MEDICINE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-926-5100
Mailing Address - Street 1:101 OLD MCCLOUD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2796
Mailing Address - Country:US
Mailing Address - Phone:530-926-5100
Mailing Address - Fax:530-926-1859
Practice Address - Street 1:101 OLD MCCLOUD RD
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2796
Practice Address - Country:US
Practice Address - Phone:530-926-5100
Practice Address - Fax:530-926-1859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADF3805OtherRAILROAD MEDICARE
CAZZZ01400ZMedicare PIN