Provider Demographics
NPI:1841244167
Name:GOODELL, MARYELLEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYELLEN
Middle Name:R
Last Name:GOODELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 FRANKLIN SQUARE DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3936
Mailing Address - Country:US
Mailing Address - Phone:443-777-2000
Mailing Address - Fax:
Practice Address - Street 1:9101 FRANKLIN SQUARE DR
Practice Address - Street 2:SUITE 205
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3936
Practice Address - Country:US
Practice Address - Phone:443-777-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33345400Medicaid
002006261WOtherHUMANA
G71623Medicare UPIN
002006261WOtherHUMANA