Healthcare Provider Details

I. General information

NPI: 1194411314
Provider Name (Legal Business Name): ALYSSA GOODMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6119
US

IV. Provider business mailing address

11133 DUNN RD
SAINT LOUIS MO
63136-6119
US

V. Phone/Fax

Practice location:
  • Phone: 314-632-9123
  • Fax:
Mailing address:
  • Phone: 314-632-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2026030039
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: