MEDICARE: ANTHONY GOODEN JR.

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	2255A2300X	Athletic Trainer		OH
2	390200000X	Student in an Organized Health Care Education/Training Program		OH

General Provider Information

NPI Number	:	1770961807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY GOODEN JR.

Provider Business Mailing Address
First Line	:	6301 STONEY CREEK DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-3657
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 STONEY CREEK DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-3657
Country	:	US
Telephone Number	:	937-443-7307
Fax Number	:

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

Provider Enumeration Date	:	05/08/2015
Last Update Date	:	05/08/2015

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Directions to “ ANTHONY GOODEN JR. ” Practice Location

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