Provider Demographics
NPI:1710946686
Name:GOOD, VANCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:A
Last Name:GOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:68 FENNER AVENUE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:PA
Practice Address - Zip Code:16947-1501
Practice Address - Country:US
Practice Address - Phone:570-297-4104
Practice Address - Fax:570-297-2066
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018594E207R00000X
NY151601-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110209499OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
PA0006852610002Medicaid
NY00364961Medicaid
PAGU040074OtherMEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
28217Medicare UPIN