Healthcare Provider Details

I. General information

NPI: 1861941650
Provider Name (Legal Business Name): EUNICE K. GOODEMOTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EUNICE K PARK PA

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-5000
  • Fax:
Mailing address:
  • Phone: 947-522-1865
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601008320
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0006214
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: