Healthcare Provider Details

I. General information

NPI: 1962065623
Provider Name (Legal Business Name): TONIA ANN GOODEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 EUCLID AVE
BERWYN IL
60402-3471
US

IV. Provider business mailing address

1501 KINGS HIGHWAY INTERNAL MEDICINE
SHREVEPORT LA
71130-3932
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3400
  • Fax:
Mailing address:
  • Phone: 318-626-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036160134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: