MEDICARE: MARJORIE ANN GOODWIN RN-PC MA

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0813X	Geropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist	114364	MA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00169878	OTHER	MA	RAIL ROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	83-01551	OTHER	MA	EVERCARE

NPI Number	:	1679508626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARJORIE ANN GOODWIN RN-PC MA

Provider Business Mailing Address
First Line	:	129 CHISWICK RD
Second Line	:	#7
City	:	BRIGHTON
State	:	MA
Zip	:	02135-5314
Country	:	US
Telephone Number	:	617-782-5192
Fax Number	:

Provider Business Practice Location Address
First Line	:	1132 WESTFIELD ST
Second Line	:
City	:	WEST SPRINGFIELD
State	:	MA
Zip	:	01089-3878
Country	:	US
Telephone Number	:	413-592-1980
Fax Number	:	413-439-0096

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	10/22/2007

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308