Provider Demographics
NPI:1366623951
Name:ROBERT C. GOODWIN MD LLC
Entity Type:Organization
Organization Name:ROBERT C. GOODWIN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-644-9191
Mailing Address - Street 1:1726 ELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2739
Mailing Address - Country:US
Mailing Address - Phone:860-644-9191
Mailing Address - Fax:860-644-9191
Practice Address - Street 1:1726 ELLINGTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2739
Practice Address - Country:US
Practice Address - Phone:860-644-9191
Practice Address - Fax:860-644-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-25
Last Update Date:2007-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16361261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO2888Medicare UPIN