1639171481 NPI number — DR. MICHAEL WILLIAM GOODMAN M.D.

Table of content: DR. MICHAEL WILLIAM GOODMAN M.D. (NPI 1639171481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639171481 NPI number — DR. MICHAEL WILLIAM GOODMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
MICHAEL
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639171481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
979 E 3RD ST
Provider Second Line Business Mailing Address:
SUITE C0630
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37403-2136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-267-5677
Provider Business Mailing Address Fax Number:
423-267-6179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
979 E 3RD ST
Provider Second Line Business Practice Location Address:
SUITE C0630
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37403-2136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-267-5677
Provider Business Practice Location Address Fax Number:
423-267-6179
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  015401 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 026122 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 192613 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3006410 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100005904 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 621553135003 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: GT23445 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".




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