Healthcare Provider Details

I. General information

NPI: 1346231842
Provider Name (Legal Business Name): ROBERT J GOODWILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HIGH PT
FORT MADISON IA
52627-3100
US

IV. Provider business mailing address

5 HIGH PT
FORT MADISON IA
52627-3100
US

V. Phone/Fax

Practice location:
  • Phone: 319-372-8287
  • Fax:
Mailing address:
  • Phone: 319-372-8287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32100
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number32100
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3168252
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier48652
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: