Healthcare Provider Details

I. General information

NPI: 1598028060
Provider Name (Legal Business Name): SUSANNAH BURNS GOODMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 LAKESIDE COMMONS DR
MACON GA
31210-5778
US

IV. Provider business mailing address

314 COCHRAN RD
CONCORD GA
30206-2903
US

V. Phone/Fax

Practice location:
  • Phone: 478-254-2644
  • Fax: 478-254-4924
Mailing address:
  • Phone: 404-664-7264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN157565
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: