Healthcare Provider Details

I. General information

NPI: 1710984794
Provider Name (Legal Business Name): IRA J GOODMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7055 HIGH GROVE BLVD SUITE 10
BURR RIDGE IL
60527-7593
US

IV. Provider business mailing address

7055 HIGH GROVE BLVD SUITE 100
BURR RIDGE IL
60527-7593
US

V. Phone/Fax

Practice location:
  • Phone: 630-371-9980
  • Fax: 630-371-9983
Mailing address:
  • Phone: 630-371-9980
  • Fax: 630-371-9983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036082680
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: