Healthcare Provider Details

I. General information

NPI: 1104317999
Provider Name (Legal Business Name): KALIE MARIE GOODMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 CENTENNIAL WAY
GREENVILLE SC
29605-4662
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-522-8000
  • Fax: 864-522-8005
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number13271767-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL52459
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number13271767-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number92979
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: