Provider Demographics
NPI:1114131646
Name:GOODGAME, KEVIN FITZGERALD (MPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:FITZGERALD
Last Name:GOODGAME
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 ARBOR GATES DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5615
Mailing Address - Country:US
Mailing Address - Phone:213-804-0727
Mailing Address - Fax:
Practice Address - Street 1:4205 ARBOR GATES DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5615
Practice Address - Country:US
Practice Address - Phone:213-804-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT8220225100000X
CAPT24148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist