Provider Demographics
NPI:1821039173
Name:GOODMAN, PETER M (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48068-0100
Mailing Address - Country:US
Mailing Address - Phone:248-849-3137
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029764207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103394992Medicaid
MI104274934Medicaid
MIPG029764OtherBC/BS OF MICHIGAN
MIM48310027Medicare ID - Type Unspecified
MI104274934Medicaid