MEDICARE: MARVIN L GOODMAN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	R0069405	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538146733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIN L GOODMAN CRNA

Provider Business Mailing Address
First Line	:	PO BOX 450816
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74345-0816
Country	:	US
Telephone Number	:	918-787-8980
Fax Number	:

Provider Business Practice Location Address
First Line	:	1310 S MAIN ST
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74344-5304
Country	:	US
Telephone Number	:	918-786-2243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	07/01/2008

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