Provider Demographics
NPI:1700868163
Name:GOODMAN, ELLIOT R
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:R
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:PO BOX 95000-2424
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2424
Mailing Address - Country:US
Mailing Address - Phone:212-420-4520
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:BIMC DEPT OF SURGERY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-420-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271199208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01706418Medicaid
NY01706418Medicaid
G28353Medicare UPIN