Healthcare Provider Details

I. General information

NPI: 1538146733
Provider Name (Legal Business Name): MARVIN L GOODMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 S MAIN ST
GROVE OK
74344-5304
US

IV. Provider business mailing address

PO BOX 450816
GROVE OK
74345-0816
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-2243
  • Fax:
Mailing address:
  • Phone: 918-787-8980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0069405
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: