Provider Demographics
NPI:1710991955
Name:GODBOUT, EDMOND (PA)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:GODBOUT
Suffix:
Gender:M
Credentials:PA
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 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI01/15/2008OtherNHPRI
1710991955OtherNPI
RI7008105Medicaid
RI04/01/2008OtherBCBSRI
RI939025129OtherRI MEDICARE GROUP NUMBER
RI1962455022OtherUEMF GROUP NPI
RI007008105Medicare ID - Type Unspecified
RIS66027Medicare UPIN