Provider Demographics
NPI: | 1164654729 |
---|---|
Name: | JACK GOODMAN, M.D. PC |
Entity Type: | Organization |
Organization Name: | JACK GOODMAN, M.D. PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JACK |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GOODMAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 845-454-0415 |
Mailing Address - Street 1: | 9 LIVINGSTON ST |
Mailing Address - Street 2: | SUITE 9 |
Mailing Address - City: | POUGHKEEPSIE |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 12601-4719 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 845-454-0415 |
Mailing Address - Fax: | 845-454-0914 |
Practice Address - Street 1: | 9 LIVINGSTON ST |
Practice Address - Street 2: | SUITE 9 |
Practice Address - City: | POUGHKEEPSIE |
Practice Address - State: | NY |
Practice Address - Zip Code: | 12601-4719 |
Practice Address - Country: | US |
Practice Address - Phone: | 845-454-0415 |
Practice Address - Fax: | 845-454-0914 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-08-17 |
Last Update Date: | 2009-08-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 086055 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |