Provider Demographics
NPI:1609805001
Name:GOOD, MARY E (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9625 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:BRIDGMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49106-9559
Mailing Address - Country:US
Mailing Address - Phone:269-465-6050
Mailing Address - Fax:269-465-3134
Practice Address - Street 1:9625 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:BRIDGMAN
Practice Address - State:MI
Practice Address - Zip Code:49106-9559
Practice Address - Country:US
Practice Address - Phone:269-465-6050
Practice Address - Fax:269-465-3134
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970016336OtherRAILROAD MEDICARE
S41569Medicare UPIN
MI970016336OtherRAILROAD MEDICARE