Provider Demographics
NPI:1598184707
Name:GOODMAN, BRENTON
Entity Type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:
Last Name:GOODMAN
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 1:1539 N BOSWORTH AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:2-SOUTH
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:765-586-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125067501207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program