Provider Demographics
NPI:1437283983
Name:BOARD CERTIFIED PLASTIC SURGEON, P.A.
Entity Type:Organization
Organization Name:BOARD CERTIFIED PLASTIC SURGEON, P.A.
Other - Org Name:RAYMOND C. GOODMAN JR, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:479-452-9080
Mailing Address - Street 1:2717 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5100
Mailing Address - Country:US
Mailing Address - Phone:479-452-9080
Mailing Address - Fax:479-452-7014
Practice Address - Street 1:2717 S 74TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5100
Practice Address - Country:US
Practice Address - Phone:479-452-9080
Practice Address - Fax:479-452-7014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105795001Medicaid
ARD79448Medicare UPIN
AR5C282Medicare PIN