Healthcare Provider Details

I. General information

NPI: 1780632950
Provider Name (Legal Business Name): ELIZABETH GOODMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET MASSACHUSETTS GENERAL HOSPITAL MS100C
BOSTON MA
02114-2696
US

IV. Provider business mailing address

55 FRUIT STREET MASSACHUSETTS GENERAL HOSPITAL MS100C
BOSTON MA
02114-2696
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-6631
  • Fax: 617-726-1886
Mailing address:
  • Phone: 617-643-6631
  • Fax: 617-726-1886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number77069
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: