Healthcare Provider Details

I. General information

NPI: 1770823585
Provider Name (Legal Business Name): WILLIAM A. GOODFELLOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S. BATAVIA AVE.
GENEVA IL
60134
US

IV. Provider business mailing address

1010 S. BATAVIA AVE.
GENEVA IL
60134
US

V. Phone/Fax

Practice location:
  • Phone: 630-337-9490
  • Fax:
Mailing address:
  • Phone: 630-337-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036-042732
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: