Provider Demographics
NPI:1134182892
Name:GOODELL, THOMAS L (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:GOODELL
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 1:400 ANN ST NW
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2052
Mailing Address - Country:US
Mailing Address - Phone:616-808-3944
Mailing Address - Fax:616-808-3948
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:METRO HEALTH - HOSPITAL
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-808-3944
Practice Address - Fax:616-808-3948
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014480207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4173010Medicaid
MITG014480OtherBCBS
MI050D110480OtherBCBS
MICE1952OtherRAILROAD MEDICARE GROUP #
MIP00137306OtherRAILROAD MEDICARE
MI5410221OtherBCBS
MI5410221OtherBCBS
MIM38730009Medicare ID - Type Unspecified