Healthcare Provider Details

I. General information

NPI: 1841968351
Provider Name (Legal Business Name): MAXWELL GOODMANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SHERMAN ST STE 160
SAINT PAUL MN
55102-2425
US

IV. Provider business mailing address

360 SHERMAN ST STE 160
SAINT PAUL MN
55102-2425
US

V. Phone/Fax

Practice location:
  • Phone: 651-291-9000
  • Fax:
Mailing address:
  • Phone: 651-291-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number1104163187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: