Healthcare Provider Details

I. General information

NPI: 1558306944
Provider Name (Legal Business Name): CHRISTOPHER K GOODWIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/27/2023
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 W CENTRE AVE
PORTAGE MI
49024-4828
US

IV. Provider business mailing address

2680 W CENTRE AVE
PORTAGE MI
49024-4828
US

V. Phone/Fax

Practice location:
  • Phone: 269-324-2400
  • Fax: 269-327-0450
Mailing address:
  • Phone: 269-324-2400
  • Fax: 269-327-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40268
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40268
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: