Healthcare Provider Details

I. General information

NPI: 1457312050
Provider Name (Legal Business Name): RUSSEL L GOODWIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S 4TH ST
DANVILLE KY
40422-2004
US

IV. Provider business mailing address

303 S 4TH ST
DANVILLE KY
40422-2004
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-1080
  • Fax: 859-236-1862
Mailing address:
  • Phone: 859-236-1080
  • Fax: 859-236-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16364
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: