Provider Demographics
NPI:1538302484
Name:GOODWIN, RD EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:RD
Middle Name:EDWARD
Last Name:GOODWIN
Suffix:JR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RD
Other - Middle Name:EDWARD
Other - Last Name:GOOODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:284 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3730
Mailing Address - Country:US
Mailing Address - Phone:708-757-0455
Mailing Address - Fax:
Practice Address - Street 1:284 E 16TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3730
Practice Address - Country:US
Practice Address - Phone:708-757-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG35072562083343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid