Provider Demographics
NPI:1841662020
Name:GOODWIN MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:GOODWIN MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ SOLE MEMBER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:DALTON
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-547-0433
Mailing Address - Street 1:431 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5210
Mailing Address - Country:US
Mailing Address - Phone:256-547-0433
Mailing Address - Fax:256-547-0460
Practice Address - Street 1:431 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5210
Practice Address - Country:US
Practice Address - Phone:256-547-0433
Practice Address - Fax:256-547-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10270G2201OtherMEDICARE GROUP PTAN
511-69544OtherBLUE CROSS BLUE SHIELD LOCATION ID NUMBER