Provider Demographics
NPI:1720262637
Name:BRIAN GOODWIN DPM PC
Entity Type:Organization
Organization Name:BRIAN GOODWIN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-651-0008
Mailing Address - Street 1:4737 24 MILE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-3148
Mailing Address - Country:US
Mailing Address - Phone:248-651-0008
Mailing Address - Fax:248-651-6988
Practice Address - Street 1:4737 24 MILE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3148
Practice Address - Country:US
Practice Address - Phone:248-651-0008
Practice Address - Fax:248-651-6988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIAN GOODWIN DPM PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-27
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1461520001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4661520001Medicare NSC