Provider Demographics
NPI:1831310226
Name:GOODWIN, SCOTT R (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:GOODWIN
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 1:3122 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3014
Mailing Address - Country:US
Mailing Address - Phone:773-769-9200
Mailing Address - Fax:773-506-6083
Practice Address - Street 1:3122 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3014
Practice Address - Country:US
Practice Address - Phone:773-769-9200
Practice Address - Fax:773-506-6083
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-129556207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036129556Medicaid
IL036129556Medicaid
IL0727500007Medicare NSC