Provider Demographics
NPI:1164481867
Name:PIEDMONT PSYCHIATRIC SERVICE PA
Entity Type:Organization
Organization Name:PIEDMONT PSYCHIATRIC SERVICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODBAR
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:864-676-9211
Mailing Address - Street 1:2094 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5939
Mailing Address - Country:US
Mailing Address - Phone:864-676-9211
Mailing Address - Fax:864-676-9432
Practice Address - Street 1:2094 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5939
Practice Address - Country:US
Practice Address - Phone:864-676-9211
Practice Address - Fax:864-676-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14711261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2107Medicaid
SCGP2107Medicaid
SCG92984Medicare UPIN
SCD90881Medicare UPIN
SC5917Medicare ID - Type UnspecifiedSC PART B MCR GRP #
SCD18206Medicare UPIN
SCGP2107Medicaid
SC=========OtherEIN #