Provider Demographics
NPI:1851402150
Name:THOMAS P GOODELL MD PC
Entity Type:Organization
Organization Name:THOMAS P GOODELL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:GOODELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-742-9940
Mailing Address - Street 1:3810 GRAND AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070
Mailing Address - Country:US
Mailing Address - Phone:307-742-9940
Mailing Address - Fax:307-742-9946
Practice Address - Street 1:3810 GRAND AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070
Practice Address - Country:US
Practice Address - Phone:307-742-9940
Practice Address - Fax:307-742-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6971A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D85804Medicare UPIN
W10038Medicare ID - Type Unspecified