Provider Demographics
NPI:1376974907
Name:GOODALL, GRANT STEVEN
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:STEVEN
Last Name:GOODALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2364
Mailing Address - Country:US
Mailing Address - Phone:513-585-5502
Mailing Address - Fax:
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-585-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-08
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 15524 NA367500000X
OHCOA.15524NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
311105593006OtherTRICARE
OH$$$$$$$$$00OtherBUREAU OF WORKERS COMPENSATION
OHP01304043Medicare PIN
OH$$$$$$$$$00OtherBUREAU OF WORKERS COMPENSATION