Provider Demographics
NPI:1013956663
Name:GOODMAN, JAMIE C (DO)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:C
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DO
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 740013
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0013
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:6119 WHITE HORSE RD STE 14
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3838
Practice Address - Country:US
Practice Address - Phone:864-614-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1433207Q00000X
VA0102201965207Q00000X
SC37735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3300104Medicaid
TN4134193OtherBLUE CROSS
SC377355Medicaid
VA1013956663Medicaid
TN3300103Medicaid
TN4149923OtherBLUE CROSS
TN3300102Medicaid
TNP00357325OtherRAILROAD MEDICARE
TN3300102Medicare ID - Type Unspecified
TN3300103Medicare PIN
TN3300103Medicaid
TNI05017Medicare UPIN
VAV V2159BMedicare PIN