Healthcare Provider Details

I. General information

NPI: 1609805001
Provider Name (Legal Business Name): MARY E GOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9625 RED ARROW HWY
BRIDGMAN MI
49106-9559
US

IV. Provider business mailing address

9625 RED ARROW HWY
BRIDGMAN MI
49106-9559
US

V. Phone/Fax

Practice location:
  • Phone: 269-465-6050
  • Fax: 269-465-3134
Mailing address:
  • Phone: 269-465-6050
  • Fax: 269-465-3134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002600
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: