Healthcare Provider Details

I. General information

NPI: 1104028489
Provider Name (Legal Business Name): GOODMAN MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 STATE ROUTE CC
ROLLA MO
65401-4402
US

IV. Provider business mailing address

PO BOX 918
ROLLA MO
65402-0918
US

V. Phone/Fax

Practice location:
  • Phone: 573-308-5044
  • Fax: 573-341-5300
Mailing address:
  • Phone: 573-308-5044
  • Fax: 573-341-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KARENE MARIE GOODMAN
Title or Position: COOWNER
Credential: NP
Phone: 573-308-5044