Healthcare Provider Details

I. General information

NPI: 1376974907
Provider Name (Legal Business Name): GRANT STEVEN GOODALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2013
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

V. Phone/Fax

Practice location:
  • Phone: 513-585-5502
  • Fax:
Mailing address:
  • Phone: 513-585-5502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA 15524 NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: