Healthcare Provider Details

I. General information

NPI: 1053570929
Provider Name (Legal Business Name): LAURA M GOODELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 BARRETT ST DILLON COMMUNITY HEALTH CENTER
DILLON MT
59725-3508
US

IV. Provider business mailing address

220 W GLENDALE ST
DILLON MT
59725-2419
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-4440
  • Fax: 406-683-1121
Mailing address:
  • Phone: 406-839-3093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12780
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: